documenting+reporting--PrepU

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? A. "Are you questioning the care of your child?" B. "Only the client has the right to review the health care records." C. "No, the physician will not give you access to review the records." D. "I will arrange access for you to review the record after you put your request in writing."

D. "I will arrange access for you to review the record after you put your request in writing."

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? A. "The care plan shows the medical diagnosis for the client." B. "The care plan provides additional documentation about the work of the nurse." C. "The care plan is the only way for nurses to document what they do." D. "The care plan is required for every client by The Joint Commission."

D. "The care plan is required for every client by The Joint Commission."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? "Only authorized persons are allowed to access client records." "The provider will need to give permission for you to review." "Let me get that for you." "I am sorry I can't access that information."

"Only authorized persons are allowed to access client records."

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? A. The client appears comfortable and is resting adequately and appears to not be in acute distress. B. The client appears to have a low tolerance for pain and frequently reports intense pain. C. The client is receiving sufficient relief from pain medication, stating no pain in either knee. D. The client reports that on a scale of 0 to 10, the current pain is a 3.

D. The client reports that on a scale of 0 to 10, the current pain is a 3.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: A. using only those abbreviations that are defined in full at another location in the client's chart. B. ensuring that abbreviations are understandable to clients who may seek access to their health records. C. using only abbreviations whose meaning is self-evident to an educated health professional. D. limiting abbreviations to those approved for use by the institution.

D. limiting abbreviations to those approved for use by the institution.

In SBAR, what does R stand for? A. Reinforcing data B. Recommendations C. Response D. Report

B. Recommendations

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? A. 1 bottle of glucose B. 1U of glucose C. 1 Unit of glucose D. One U of glucose

C. 1 Unit of glucose

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? "I am concerned that the client might be exhibiting sepsis." "The client's temperature has been 102°F (38.9°C) for the last 6 hours." "Will you prescribe a complete blood count to check the white blood cell count and a culture?" "The client was admitted today with a urinary tract infection."

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A. A client has asked a nurse if he can read the documentation that his physician wrote in his chart. B. A client who resides in Indiana has required hospitalization during a vacation in Hawaii. C. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. D. A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test.

A. A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

Which principle should guide the nurse's documentation of entries on the client's health care record? A. Precise measurements should be used rather than approximations. B. Correcting fluid is used rather than erasing errors. C. Documentation does not include photographs. D. Nurses should not refer to the names of physicians.

A. Precise measurements should be used rather than approximations.

A nurse receives a subpoena for a lawsuit involving a client who retained a foreign body after undergoing a surgical procedure. The nurse reviews the chart prior to the court date and observes that some data are missing from the document and some entries are incorrect. What is the appropriate action by the nurse? A. continue reviewing the document without making any written corrections to what is present B. draw a line through the information that is incorrect and write corrections on the document C. use "white-out" to cover the incorrect information in the document

A. continue reviewing the document without making any written corrections to what is present

Which are appropriate actions for protecting clients' identities? Select all that apply. A. Orient computer screens toward the public view. B. Place light boxes for examining X-rays with the client's name in private areas. C. Ensure that clients' names on charts are visible to the public. D. Have conversations about clients in private places where they cannot be overheard. E. Document all personnel who have accessed a client's record.

B. Place light boxes for examining X-rays with the client's name in private areas. D. Have conversations about clients in private places where they cannot be overheard. E. Document all personnel who have accessed a client's record.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? A. "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." B. "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin." C. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." D. "I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin."

C. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? A. "It will let me see everything that has been done and things that need to be done." B. "It will give me a better sense of what my workload will be today." C. "It makes our client feel like we care, especially if we start the day off with a clean room." D. "It will allow for us to see the client and possibly increase client participation in care."

D. "It will allow for us to see the client and possibly increase client participation in care."

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: A. important information. B. factual statement. C. relevant data. D. interpretation of data.

D. interpretation of data.