Chapter 4: Validating and Documenting Data

Which of the following data entries follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write

"bilateral lung sounds clear."

The nurse manager intervenes when which of the following is observed?

A nurse provides the spouse of a client access to the client's medical record.

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?

Ask the other nurse to read back what first nurse reported

The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?

Assessment data in the medical record

The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?

Client safety increases

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?

Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

After performing a comprehensive assessment on a new client, the nurse documents the following findings. Which documentation follows acceptable documentation guidelines?

Client states, "I don't want to eat or do anything."

The nurse is performing a focused assessment on a client who reports several episodes of dizziness on standing. How should the nurse document the findings?

Client states, "I have frequently felt dizzy when standing the past 2 weeks," heart rate 94, BP 105/70mm Hg, skin turgor elastic, voiding 3 liters/day.

Which assessment is most likely performed when a client is admitted to the hospital?

Comprehensive

A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?

Cued or checklist forms

During the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. Which of the following demonstrates the most appropriate documentation of these findings?

Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye.

A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?

Details are often missing

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?

Evidence in a situation of wrongdoing

During an accrediting agency visit, it is found that some client care standards are not being met. Where should problem solving occur in this instance?

Facility level

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

Focused

On reviewing a client's database following a physical examination, a nurse realizes that the client's weight has been steadily increasing over her past three visits. What follow-up question would be best for the nurse to pose to the client based on this finding?

Has your diet or exercise changed significantly in the past year?

When charting by exception is used in a health care agency, the most important aspect of this method is what?

Identifying the standards and norms for the institution

How does the client's medical record affect financial reimbursement?

Insurance companies audit client records to ensure that billing is accurate

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?

It allows several health team members to view the client record simultaneously.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Limiting abbreviations to those approved for use by the institution.

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?

Narrative notes

In order to help out the staff in completing admission tasks during a busy shift, the charge nurse is completing the admission database for a staff nurse. What is the charge nurse's best action?

Place the completed assessment in the medical record.

A client with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the client's chart. The nurse knows to look at what part of the client's medical record to check the current medical diagnosis?

Progress notes

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?

Reassess blood pressure

The nurse manager at an extended care facility is incorporating bar code scanners into client care. Bar code scanners have been utilized in client care to address which issue of quality hospital care?

Reduction in medical error

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?

SBAR

A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?

Specialty area assessment form

To make a legal entry into the medical record, the nurse must document what?

Time of the assessment

After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?

To communicate effectively with other health care team members

A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?

To provide a record of the actual events

The nurse is providing care to a client who has had a significant change in their vital signs and worsening symptoms. How should the nurse communicate these new findings to the health care provider?

Use the SBAR model.

A client has been prescribed a new medication. What action is most important for the nurse to take prior to administration?

Verify client allergies to medications.

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Verify the data by having another nurse come in to perform the percussion.

A new order for intravenous (IV) antibiotics has been prescribed for a female client who is hospitalized. The nurse reviews the client's chart, which indicates no known drug allergies and an admission diagnosis of a urinary tract infection (UTI). What is the first action of the nurse?

Verify whether the client has allergies.

The nursing instructor is demonstrating to the student how to perform a physical assessment on a client. The instructor stresses the importance of being precise when doing an assessment. Another necessary aspect of the assessment to render safe and effective care is which of the following:

accurate documentation

The nurse is preparing to document assessment findings in a client's record. The nurse should

avoid slang terms or labels unless they are direct quotes.

A nurse is caring for a client who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:

charting by exception

f the nurse makes an error while documenting findings on a client's record, the nurse should

draw a line through the error, writing "error" and initialing.

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form

prevents missed questions during data collection.

What information concerning a client's respirations should the nurse record after completing a general physical assessment?

rate, rhythm, and depth of respirations taken for a full minute

One disadvantage of the open-ended assessment form is that it

requires a lot of time to complete.

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should

validate all data before documentation of the data.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?

It provides quick access to abnormal findings.