Exam 1- Prep U review- ch10/19

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information." The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.

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 client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.

Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies?

"We will be having a team conference to discuss concerns that clients' relatives have raised." Dont do this at change of shift report Team conferences are effective communication strategies to discuss the relatives' concerns because this usually involves the multidisciplinary team and the relatives could be involved. Change-of-shift report is incorrect since this is only a summary of each client's condition and current status of care in a discussion between the personnel of the outgoing and incoming shifts. Client assignment identifies the clients for whom the staff person is responsible and describes their care and is therefore incorrect. Nursing rounds is incorrect since this strategy provides the staff the opportunity to observe and converse in the client's presence and boost the client's confidence.

Conflict has emerged on a nursing unit due to the perception by new graduates that some of the more experienced nurses are manipulating the client assignment to ensure a lighter workload during night shifts. How should the manager of the unit best address this conflict?

Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible. Open, explicit, and participatory conflict resolution that is based on collaboration is an effective strategy for the management of conflict.

A nurse informs the client that the client has no choice and must take a bath in the morning. What type of leadership does this exemplify?

Directive Leadership Directive (also known as autocratic or authoritarian) leadership describes a leader who makes all the decisions and tells followers what to do.

Which charting format permits documentation on any significant topic, not just client problems?

FOCUS FOCUS charting permits documentation on any significant topic. It is organized around data, action, and response. Each of the remaining responses center their documentation on the identification of a problem.

Focus-charting method benefits

Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed. Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

Legal Document The client record serves as a legal document of the client's health status and care received. An assessment tool may be a formal document that is included as part of the client's record. A Kardex is typically an erasable, temporary document that would be shredded when no longer needed for the client's care. Incident reports are internal documents that are not a part of the client's record, and therefore not a legal document regarding their health care.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records

PIE charting method benefits

PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified).

An inner-city hospital is seeing a declining client census. The nurse managers begin to strategically plan to determine ways to increase their client population. In the implementation of these strategies, they also evaluate their success and failure and renew their plan. This activity is:

Problem solving Management involves getting a job done or accomplishing a goal. The process they use is similar to the problem-solving process, which is based on the scientific or research method. The nurses are not making directive initiatives. Although this work is a continuing process, this description is too vague. Nurses cannot control patient outcomes; they can only hope to improve them by making changes that may or may not work.

The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy - this action immediately protects the clients privacy

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

SUBJECTIVE Data quotes maintain accuracy

A nurse is documenting care for an older adult client who is recovering from a mild stroke. Which documentation entries follow the recommended guidelines for communicating and documenting client information? Select all that apply.

The client rates pain as 2 compared to a 7 yesterday. Vital signs returned to normal. Radial pulse 72, strong and regular NORMAL is an okay term to use for baseline

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions. Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health histories and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

Problem-oriented method benefits

The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

assess the need for assistance with ambulation. Thus, the nurse should assess the client's ability to ambulate independently before allowing the client to go to the restroom and to provide assistance, if needed. The nurse would lower, not raise, the bedside rails before having the client exit the bed. The nurse would put nonskid footwear like slippers, not socks, on the client to help prevent falls. Furniture should be arranged so that the client has a clear and easy path to the restroom.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP?

initiating intravenous therapy

What dual purpose does an audit serve?

quality assurance and reimbursement Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits have no role in communications, evaluation, knowledge, quality, education, or confidentiality,

source-oriented method benefits

Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically.

A nurse is in charge of a large group of employees on a busy surgical floor. Today's care must be completed early due to a special event involving most of the employees. Which management style would work best in this situation?

Authoritarian It is particularly effective when decisions for a large group need to be made quickly and efficiently, as in this scenario

The nurses who provide care on a medical unit are skeptical about the planned change from a traditional narcotic cupboard to a computerized medical supply and management system. Which statement best demonstrates mistrust about the benefits of this proposed change?

"I've heard those machines don't even cut down on medication errors like they say they do." Resistance to change takes many forms, including doubts about the benefits of a change. Expressing doubt that a new process will reduce medication errors expresses such a doubt. Fears about the necessary learning, cost, and effects on workload are also common points of resistance, but these do not focus on the purported benefits.

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best?

"The UAP is able to log in and enter the information so all members of the health care team can see it." Each person who makes entries in the client's electronic health record (EHR) is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. Although the licensed registered nurse has accountability, the UAP can document data that has been collected in the EHR. It is not appropriate to document for someone else, and all users should always log out of the computer prior to allowing another person to document.

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents?

Client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

A nurse manager values group satisfaction and tries to motivate the staff to be the best nurses possible. In which style of leadership is the group satisfaction and motivation the primary benefit?

Democratic also called participative leadership

Difference between Democratic, Autocratic, Laissez-faire, and transformational leadership styles

Democratic leadership, also called participative leadership, is characterized by a sense of equality among the leader and other participants. Autocratic leadership, also called directive leadership or authoritarian leadership, involves the leader assuming control over the decisions and activities of the group. In laissez-faire leadership, also called nondirective leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group. Transformational leaders have a positive and compelling vision, fostering a new culture for nursing practice and client care. This style of leadership is a key component of organizations that achieve Magnet® status.

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records. The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply.

Showing the provider the trends from baseline to present in blood pressure Informing the provider of the client's present heart rate of 116 beats/min Faxing the results of blood chemistry levels to the provider's office Reporting to the primary care provider can occur face-to-face, by telephone, by text messaging, or, in some settings (e.g., long-term or home care), by fax.

A nurse is caring for a client with pneumonia. Which task is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

Obtaining vital signs every 4 hours Having the UAP obtain vital signs every 4 hours is most appropriate, as it is within the UAP's scope of practice to perform this task. Assessment, teaching, and administration of medication are not in the current scope of practice for UAPs.

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method

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

Progress notes

The nurse recognizes that a new mother is having difficulty breastfeeding. The nurse demonstrates various positions in which to hold the baby while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the baby again using the new techniques and is successful. Which statement in this scenario illustrates Lewin's stage of refreezing?

The new mother attempts to breastfeed the baby again using the new techniques and is successful. Refreezing involves making a change operational, or a part of one's everyday life. The mother feeding the baby using new techniques is an example of refreezing. The nurse recognizing that a new mother is having difficulty breastfeeding is an example of unfreezing, in which the need for a change is recognized. The nurse educating the mother on ways to ensure proper latching and demonstrating various positions in which to hold the baby while feeding are examples of moving, in which change is initiated after a careful process of planning.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

The registered nurse (RN) wants to delegate measuring a client's urinary output to an unlicensed assistive personnel (UAP). Which factors should the nurse consider before delegating the task?

The stability of the patient's condition, potential for harm, and complexity of the activity

Two nurses are having a disagreement over who will take the next admission to the unit. The nurse manager asks one of the nurses to take the admission and explains that this will be considered a personal favor. Which style of conflict resolution did the nurse manager display?

accommodating The nurse manager is displaying a conflict resolution style of accommodating by asking one of the nurses to accept the assignment of the admission. If the nurse manager had ignored the situation, this would have been the avoiding style of conflict resolution. With a competing style, the nurse manager would have told the nurse to accept the admission, rather than asking the nurse. If collaborating is the conflict resolution style used, the nurse manager would have discussed the situation with both nurses in order to achieve a solution to this conflict.