Fundamentals, (ch, 19 Documenting and Reporting)

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? Documentation Verification Reporting Dialogue

Reporting

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? Abnormal laboratory values are common items that are documented. The plan includes interventions, evaluation, and response. Objective data are what the client states about the problem. Subjective data should be included when documenting.

Subjective data should be included when documenting.

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? "The CABG procedure will help identify nutritional needs." "A coronary artery bypass graft will benefit your heart." "A complete ablation of the biliary growth will decrease liver inflammation." "The CABG procedure will help increase intestinal motility and prevent constipation."

"A coronary artery bypass graft will benefit your heart."

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? Accessing the electronic health record of the family member to find out extent of injury Finding the emergency medical technicians who transported the family members and inquiring about the injuries Asking the emergency department nurse for information on the family member Calling the client information desk to find out the room number of the family member

Calling the client information desk to find out the room number of the family member

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? Call the pharmacy to have the order entered in the electronic record. Write the order in the client's record. Inform the health care provider that a written order is needed. Add the new order to the medication administration record.

Inform the health care provider that a written order is needed.

The nurse in making an entry on the client's chart: "Medicated with meperidine 50 mg at midnight." How would the nurse document the entry using military time? 0000 1200 2401 1201

0000 or could be 2400 not 2401 the

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

1 Unit of glucose

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? Select all that apply. 1-Conversations about clients must take place in private places where they cannot be overheard. 2-The names of the clients on charts should be visible to the public. 3-Light boxes for examining X-rays with the client's name must be in private areas. 4-Computer screens must be oriented toward the public view. 5-Documentation must be kept of personnel who have accessed a client's record.

5-Documentation must be kept of personnel who have accessed a client's record. 3-Light boxes for examining X-rays with the client's name must be in private areas. 1-Conversations about clients must take place in private places where they cannot be overheard.

Which statement is not true regarding a medication administration record (MAR)? When using an electronic MAR, the nurse has to log off so that the next person using the computer does not sign off a medication under her name by mistake. If the client refuses the dose you don't have to document this on the MAR. The MAR identifies routine times for medication administration. The MAR distinguishes between routine and "as needed" medications

If the client refuses the dose you don't have to document this on the MAR.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? Telemedicine report Transfer report Nurse's shift report Incident report

Incident report

Which abbreviation is correct for use in documentation? BT PO Per os Sub q

PO

The nurse makes an erroneous entry into the written health record. What is the appropriate nursing action? Place one line through the entry and initial it. Write over the entry in another color pen. Scribble through the entry. Obtain white-out to cover the entry.

Place one line through the entry and initial it.

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

Precise measurements should be used rather than approximations.

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care. Problem-oriented recording gives clients the right to withhold the release of their information to anyone.

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

How can a nurse obtain additional information about a client? Ask the client's sister about the family history. Review nursing literature. Call the client's family. Read the client's history and assessment.

Read the client's history and assessment.

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? Document the UAP's conversation. Notify the client relations department about the breach of privacy. Remind the UAP about the client's right to privacy. Report the UAP to the nurse manager.

Remind the UAP about the client's right to privacy.

The nursing is caring for a client who requests to see a copy of his health care records. What action by the nurse is most appropriate? Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client. Access the health care record at the bedside and show the client how to navigate the electronic health record. Review the hospital's process for allowing clients to view their health care records.

Review the hospital's process for allowing clients to view their health care records.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? PIE charting FOCUS charting narrative charting SOAP charting

SOAP charting

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? Objective data are what the client states about the problem. Subjective data should be included when documenting. Abnormal laboratory values are common items that are documented. The plan includes interventions, evaluation, and response.

Subjective data should be included when documenting.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? The client has a history of severe complaints in the morning. The client has symptoms in the morning associated with a heart attack. The client is coughing and experiencing severe heartburn in the morning. The client reports waking up this morning with a severe headache.

The client reports waking up this morning with a severe headache.

Which finding from a nursing audit reflects high standards for client safety and institutional health care? The nurse fails to adequately complete data on clients' health histories and discharge planning. The nurse fails to identify the nursing diagnoses or clients' needs. The nurse documents clients' responses to nursing interventions. The nurse records inappropriate nursing interventions.

The nurse documents clients' responses to nursing interventions.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? Talking directly to the translator facilitates the transfer of information. Talking loudly helps the translator and the client understand the information better. Translators may need additional explanations of medical terms. It is always okay to not use a translator if a family member can do it.

Translators may need additional explanations of medical terms.

A new graduate is working at a first job. Which statement is most important for the new nurse to follow? Use abbreviations approved by the facility. Use PIE charting, even if it is not the institution's charting method. Only document changes in the client's status. Document lengthy entries using complete sentences.

Use abbreviations approved by the facility.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a client whose rehabilitation potential is not good a client who is not making progress in expected outcomes of care a client who is homebound and needs skilled nursing care a client whose status is stabilized

a client who is homebound and needs skilled nursing care

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

interpretation of data.

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

interpretation of data.

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? problem list data base plan of care progress notes

progress notes

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access to the client's records? those directly involved in the client's care health care professionals of the facility

those directly involved in the client's care

Which organization audits charts regularly? National League for Nursing Sigma Theta Tau International American Nurses Association The Joint Commission

The Joint Commission

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which information would the nurse expect to include when preparing the verbal handoff report? client's admission number client's family members client's intake for previous meal current client assessment

current client assessment

A nurse working in a rural area setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation? charting by exception problem-oriented PIE charting source-oriented

source-oriented

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? "It will let me see everything that has been done and things that need to be done." "It will allow for us to see the client and possibly increase client participation in care." "It will give me a better sense of what my workload will be today." "It makes our client feel like we care, especially if we start the day off with a clean room."

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

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? following up the incident with other members of the care team gauging the nurse's professional performance over time identifying risks and ensuring future safety for clients protecting the nurse and the hospital from litigation

identifying risks and ensuring future safety for clients

To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information? releasing the client's entire health record when only portions of the information are needed failing to recognize the client's right to withhold health information for research submitting a written notice to all clients identifying the uses and disclosures of their health information failing to obtain the client's signature indicating that the client was informed of the disclosure of information

submitting a written notice to all clients identifying the uses and disclosures of their health information

A nursing instructor is discussing a nursing student's social media post about an interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate? "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." "You may continue to post about a client you cared for during clinicals, as long as you do not use the client's name." "All aspects of the clinical experience are confidential and should not be discussed." "Any information that can identify a person is considered a breach of client privacy."

"Any information that can identify a person is considered a breach of client privacy."

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? "The client's temperature is 102°F (38.9°C) for the last 6 hours." "I am concerned that the client might be exhibiting sepsis." "Will you prescribe a CBC to check the WBCs and a culture?" "The client was admitted today with a urinary tract infection."

"Will you prescribe a CBC to check the WBCs and a culture?"

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? "Clipboards with client data should not leave the unit." "Be sure to put the client's name and room number on all paperwork." "You can get an electronic printout of client lab data to take with you." "Be sure to write down specific information for your clinical paperwork."

"Clipboards with client data should not leave the unit."

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." "Let me get that for you." "I am sorry I can't access that information." "The provider will need to give permission for you to review."

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

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client? 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. 8:00: Pt is resting in bed and appears to be comfortable. 0800: Resting in bed, eating some breakfast. Complains of headache. 0800: Side rails up, call light in reach. Bed in high position.

0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? Accurately documenting client care on the client record Notifying the nursing team of the client's condition Keeping an accurate medication record Documenting client data on the flow sheet

Accurately documenting client care on the client record

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? Select all that apply. Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. The names of the clients on charts should be visible to the public. Computer screens must be oriented toward the public view. Conversations about clients must take place in private places where they cannot be overheard.

Conversations about clients must take place in private places where they cannot be overheard. Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas.

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? Documentation Clinical judgment Accreditation Psychomotor skills

Documentation

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? It provides quick access to abnormal findings. It documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number.

It provides quick access to abnormal findings.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? The client reports waking up this morning with a severe headache. The client has symptoms in the morning associated with a heart attack. The client is coughing and experiencing severe heartburn in the morning. The client has a history of severe complaints in the morning.

The client reports waking up this morning with a severe headache.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. The nurse sends or directs someone to take action in a specific nursing care problem. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care.

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours? a flow sheet a medication record a 24-hour fluid balance record acuity charting forms

a flow sheet

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: reporting. a referral. conferring. a consultation.

a referral.

To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for? recommendations reinforcing data report response

recommendations

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: can be punished for violating guidelines. have the right to copy their health records. are required to obtain health record information through their insurance company. need to obtain legal representation to update their health records.

those directly involved in the client's care

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, medical records cannot be changed." "HIPAA legislation allows for you to change any information." "HIPAA legislation only allows access to review the medical record." "According to HIPAA legislation, you have a right to request changes to inaccurate information."

"According to HIPAA legislation, you have a right to request changes to inaccurate information."