N400 Ch19: Documenting & Reporting

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

Reporting

A concise document that provides most of the client's nursing and medical information is a(n): a. past chart. b. office record. c. Kardex. d. nursing care plan.

c. Kardex.

A client's record can be more accurate if the nurse: a. summarizes client care at the end of the shift. b. charts at least every 6 hours. c. uses point-of-care documentation. d. delegates charting appropriately.

c. uses point-of-care documentation.

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

a. Use abbreviations approved by the facility.

Which is the primary purpose of client records? a. Legal protection b. Performance improvement c. Communication d. Reimbursement

c. Communication

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 is required for every client by The Joint Commission." b. "The care plan shows the medical diagnosis for the client." c. "The care plan is the only way for nurses to document what they do." d. "The care plan provides additional documentation about the work of the nurse."

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

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given? a. 2130 b. 1930 c. 930 p.m. d. 0930

a. 2130

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? a. Ask the client if information can be given to the parent. b. Explain the reasons for the hospitalization, but give no further information. c. Provide the information to the parent. d. Take the parent to the client's room and have the client give the requested information.

a. Ask the client if information can be given to the parent.

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

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

In SBAR, what does R stand for? a. Response b. Recommendations c. Report d. Reinforcing data

b. Recommendations

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? a. narrative charting b. SOAP charting c. FOCUS charting d. PIE charting

b. SOAP charting

Which example may illustrate a breach of confidentiality and security of client information? a. The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. b. The nurse provides information over the phone to the client's family member who lives in a neighboring state. c. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell. d. The nurse provides information to a professional caregiver involved in the care of the client.

b. The nurse provides information over the phone to the client's family member who lives in a neighboring state.

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

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

The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record? a. Write over the entry in another color pen. b. Scribble through the entry. c. Place one line through the entry and initial it. d. Obtain white-out to cover the entry.

c. Place one line through the entry and initial it.

Which is not a purpose of the client care record? a. To facilitate reimbursement b. To serve as a legal document c. To serve as a contract with the client d. To assist with care planning

c. To serve as a contract with the client

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? a. "The electronic health record we use does not allow us to use different formats." b. "It would be easier to do it that way. You could develop a tool to use." c. "The facility requires us to document client care this way because of the computer application used." d. "Legal policy requires nursing practice to be permanently integrated into the client record."

d. "Legal policy requires nursing practice to be permanently integrated into the client record."

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

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

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. One U of glucose d. 1 Unit of glucose

d. 1 Unit of glucose

Which is the proper way to document midnight in a client's record? a. 1200 b. 1201 c. 2401 d. 0000

d. 0000

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): a. assessment tool. b. incident report. c. Kardex. d. legal document.

d. legal document.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? a. reimbursement b. organization c. objectivity d. subjectivity

d. subjectivity

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

b. a flow sheet

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

d. Documentation

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

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

Which actions should the nurse take before making an entry in a client's record? Select all that apply. a. Identifying the form appropriate to be used for documenting b. Locating clients' files within an electronic health record system c. Choosing the charting format that the nurse prefers d. Reviewing the agency's list of approved abbreviations e. Checking that clients' names are not identified within the chart forms

a. Identifying the form appropriate to be used for documenting b. Locating clients' files within an electronic health record system d. Reviewing the agency's list of approved abbreviations

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. Nurses should not refer to the names of physicians. c. Correcting fluid is used rather than erasing errors. d. Documentation does not include photographs.

a. Precise measurements should be used rather than approximations.

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? a. Problem-oriented method b. PIE charting method c. Focus charting method d. Source-oriented method

a. Problem-oriented method

What information should the nurse document in the medication record when administering a non-narcotic pain medication? Select all that apply. a. Reason given b. Dose c. Time d. Vital signs e. Effectiveness of medication

a. Reason given b. Dose c. Time e. Effectiveness of medication

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

a. Subjective data should be included when documenting.

Which statement regarding FOCUS charting is most accurate? a. The charting focuses on client strengths, problems, or needs. b. Problem, intervention, evaluation (PIE) charting is used with FOCUS charting. c. The charting focuses on the injury or illness only. d. Each note should include each section of the data, action, response (DAR) format of charting.

a. The charting focuses on client strengths, problems, or needs.

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

a. a client who is homebound and needs skilled nursing care

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? a. "I am calling because the client receiving blood has developed dyspnea and had crackles." b. "I think the client would benefit from intravenous furosemide." c. "It seems like this client has fluid volume overload." d. "This client has a medical history of heart failure."

b. "I think the client would benefit from intravenous furosemide."

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? a. following up the incident with other members of the care team b. identifying risks and ensuring future safety for clients c. protecting the nurse and the hospital from litigation d. gauging the nurse's professional performance over time

b. identifying risks and ensuring future safety for clients

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

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

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? a. An audit b. A never event c. A variance d. A sentinel event

c. A variance

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. a. Making the names of clients on charts visible to the public b. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards c. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public d. Obscuring identifiable names of clients and private information about clients on clipboards e. Keeping record of people who have access to clients' records

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

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation? a. The nurse could be fired but would not face criminal charges or jail time. b. No action will be taken as long as the parents don't find out. c. The nurse could be fined or even go to jail for violating HIPAA. d. There will be no repercussions if the nurse takes the photo down from the social media page.

c. The nurse could be fined or even go to jail for violating HIPAA.

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? a. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. b. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. c. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. d. The nurse sends or directs someone to take action in a specific nursing care problem.

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

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? a. Heart rate and rhythm b. The abdominal area c. Lung sounds d. The lower extremities

d. The lower extremities

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take? a. Revise the plan of care. b. Review the nursing care plan. c. Involve the family in changes. d. Implement changes in the current interventions.

a. Revise the plan of care.

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

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

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? a. SOAP b. focus c. charting by exception d. narrative

c. charting by exception

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? a. Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information b. Releasing the client's entire health record when only portions of the information are needed c. Disclosing client health information for research purposes after obtaining permission from the client's physician d. Submitting a written notice to all clients identifying the uses and disclosures of their health information

d. Submitting a written notice to all clients identifying the uses and disclosures of their health information

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

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

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? a. SBAR b. MAR c. SOAP d. PIE

a. SBAR

A nurse working in a rural 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? a. Source-oriented b. PIE charting c. Problem-oriented d. Charting by exception

a. Source-oriented

A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? Select all that apply. a. There are lines between the entries. b. The content is not in accordance with professional standards. c. Dates and times of entries are omitted. d. The documentation is not countersigned. e. The content includes descriptions of situations that are out of the ordinary. f. The content reflects client needs.

a. There are lines between the entries. b. The content is not in accordance with professional standards. c. Dates and times of entries are omitted.

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? a. Translators may need additional explanations of medical terms. b. Talking loudly helps the translator and the client understand the information better. c. It is always okay to not use a translator if a family member can do it. d. Talking directly to the translator facilitates the transfer of information.

a. Translators may need additional explanations of medical terms.

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? a. Use minimum disclosure policy to release the information. b. Release the full medical record to expedite payment. c. Refer the insurance agency directly to the client. d. Do not release any information to the insurance company.

a. Use minimum disclosure policy to release the information.

Which documentation by the nurse best supports the PIE charting system? a. Vomiting 250 mL undigested food, antiemetic given, no further vomiting b. Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg c. Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea d. States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given

a. Vomiting 250 mL undigested food, antiemetic given, no further vomiting

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. a. any abnormal occurrences with the client during the shift b. what the client watched on television during the shift c. identifying demographics, including diagnosis d. what time the nurse will return for the next shift e. current orders

a. any abnormal occurrences with the client during the shift c. identifying demographics, including diagnosis e. current orders

Which components should the nurse include when documenting a critical pathway? Select all that apply. a. care plan b. expected outcomes c. timeline d. subjective data e. significant deviations

a. care plan b. expected outcomes c. timeline

A nurse in a long-term care facility is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? a. narrative note b. SOAP note c. PIE note d. flow sheet

a. narrative note

What dual purpose does an audit serve? a. quality assurance and reimbursement b. communication and evaluation c. education and confidentiality d. knowledge and quality

a. quality assurance and reimbursement

The health care provider tells the client, "You are experiencing an MI," and leaves the room. The client asks the nurse what an MI stands for. What response by the nurse is most accurate? a. "Mitochondria inflammation." b. "Myocardial infarction." c. "Muscle infection." d. "Myopia instability."

b. "Myocardial infarction."

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? a. "The client's temperature has been 102°F (38.9°C) for the last 6 hours." b. "Will you prescribe a complete blood count to check the white blood cell count and a culture?" c."The client was admitted today with a urinary tract infection." d. "I am concerned that the client might be exhibiting sepsis."

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

Which note includes all elements of a SOAP note? a. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess. b. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. c. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. d. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis.

b. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? a. "I can share the clients' medical records with the health care team." b. "The clients' medical records provide data for legal evidence." c. "The clients' medical records are an obstruction to research and education." d. "The clients' health records should be used to promote reimbursement from insurance companies"

c. "The clients' medical records are an obstruction to research and education."

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

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

The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." What is the most appropriate action by the nurse? a. Proceed with the order since the nurse heard it the first time b. Ask the secretary to call the provider back and take the order c. Inform the provider, to ensure safety for the client, it must be read back d. Don't follow through with the order, and delete it from the record

c. Inform the provider, to ensure safety for the client, it must be read back

Which strategy would provide the most effective form of change of shift report? a. Discussing the client's visitors and complaints during the prior shift. b. Providing the oncoming nurse the client's clipboard prior to leaving the unit. c. Utilizing a reporting form and allowing time for any questions. d. Recording the report for the oncoming shift prior to leaving the unit.

c. Utilizing a reporting form and allowing time for any questions.

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

c. a client who is homebound and needs skilled nursing care

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. "No, the physician will not give you access to review the records." b. "Only the client has the right to review the health care records." c. "Are you questioning the care of your child?" 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."

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? a. "No medical issues overnight that require immediate attention." b. "The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety." c. "The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." d. "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

d. "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

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? a. It provides and refers to a client's problem by a number. b. It records progress under problems, intervention, and evaluation. c. It documents assessments on separate forms. d. It provides quick access to abnormal findings.

d. It provides quick access to abnormal findings.

A client will be transferred from the cardiovascular intensive care unit to the telemetry unit for continued care. Which documentation correctly demonstrates how the nurse would prepare information to be conveyed to the receiving nurse during a verbal handoff report? a. Mr. Alfred Jones, 8 days post-CABG to correct RVEF is being transferred to the telemetry unit. Vitals are BP 130/82, P 82 and irregular, R 21, T 99.2F (37.3C). Client is currently receiving D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Oxycodone pain medication administered at 0800 along with PRN acetaminophen. b. Alfred Jones, 76-year-old male-Transferring for monitoring for the next 7 days. Vitals are stable. IV fluids are currently being administered through R wrist with D51/2 NS + 20 mEq KCl at 125 ml/hr. Pain at incision relieved with a combination of oxycodone and acetaminophen at 0845. c. MR#12345, Alfred Jones, 76-year-old male 8 days post-op for RVEF. Transferring for monitoring for the next week. Braden score 13 and vitals are stable. IV fluids are currently being administered through R wrist with D51/2 NS + 20 mEq KCl at 125 ml/hr with orders to continue for 3 days. Pain at incision rated at 4 on a scale of 0-10 relieved with a combination of oxycodone and acetaminophen at 0845 with relief within 30 minutes. d. Mr. Alfred Jones, MR#12345, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes.

d. Mr. Alfred Jones, MR#12345, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes.

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? a. 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. b. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. c. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. d. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

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

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 is receiving sufficient relief from pain medication, stating no pain in either knee. b. The client appears comfortable and is resting adequately and appears to not be in acute distress. c. The client appears to have a low tolerance for pain and frequently reports intense pain. 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.

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? a. The client has a history of severe complaints in the morning. b. The client has symptoms in the morning associated with a heart attack. c. The client is coughing and experiencing severe heartburn in the morning. d. The client reports waking up this morning with a severe headache.

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

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? a. concerned with feeling tired b. describes wound as itchy c. pain rating of 4 on a scale of 0-10 d. urine output 100 ml

d. urine output 100 ml