Nurs 222 CoursePoint Chapter 19

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which information? a) The physician's assessment and treatment. b) Results of laboratory and diagnostic studies. c) Nursing documentation and plan of care. d) Information from other members of the health care team.

a) The physician's assessment and treatment.

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) Use PIE charting, even if it is not the institution's charting method. d) Only document changes in the client's status.

a) Use abbreviations approved by the facility.

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis? a) The client's family b) The public health department c) Health Canada d) The client's employer

b) The public health department

A client's record can be more accurate if the nurse: a) Charts at least every 6 hours. b) Uses point-of-care documentation. c) Summarizes client care at the end of the shift. d) Delegates charting appropriately.

b) Uses point-of-care documentation.

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

c) Recommendations

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

c) Reporting

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 abbreviations whose meaning is self-evident to an educated health professional. b) Ensuring that abbreviations are understandable to clients who may seek access to their health records. c) Using only those abbreviations that are defined in full at another location in the client's chart. d) Limiting abbreviations to those approved for use by the institution.

d) Limiting abbreviations to those approved for use by the institution.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? a) The provider can input orders remotely into the EHR system for the nurse to retrieve. b) The nurse can implement care once written orders are received from the provider. c) The client must be stabilized before the nurse can obtain any orders from the provider. d) The nurse can accept verbal orders to provide immediate care and record once the client is stable.

d) The nurse can accept verbal orders to provide immediate care and record once the client is stable.

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) "I will arrange access for you to review the record after you put your request in writing." b) "No, the physician will not give you access to review the records." c) "Are you questioning the care of your child?" d) "Only the client has the right to review the health care records."

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

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

a) A flow sheet

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? a) Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." b) Client states expecting some pain, but it is more severe than anticipated. c) Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. d) Client is requesting pain medications, is grimacing, and is diaphoretic.

a) Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

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? a) Incident report b) Nurse's shift report c) Transfer report d) Telemedicine report

a) Incident report

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) SOAP c) PIE d) MAR

a) SBAR

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) Objective data are what the client states about the problem. c) The plan includes interventions, evaluation, and response. d) Abnormal laboratory values are common items that are documented.

a) Subjective data should be included when documenting.

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. a) The client rates pain as 2 compared to a 7 yesterday. b) The client seems comfortable today. c) The client drank an average amount of fluids. d) Vital signs returned to normal. e) The client appears anxious about having another stroke. f) Radial pulse 72, strong and regular.

a) The client rates pain as 2 compared to a 7 yesterday. d) Vital signs returned to normal. f) Radial pulse 72, strong and regular.

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? a) "The CABG procedure will help identify nutritional needs." 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 increase intestinal motility and prevent constipation."

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

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: a) Factual statement b) Interpretation of data c) Important information d) Relevant data

b) Interpretation of data

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

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

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

b) The nurse meets with nurses or other health care professionals to discuss some aspect of 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? a) Write the order in the client's record. b) Call the pharmacy to have the order entered in the electronic record. c) Inform the health care provider that a written order is needed. d) Add the new order to the medication administration record.

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

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

c) Precise measurements should be used rather than approximations.

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

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

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

c) The lower extremities

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

c) The nurse documents clients' responses to nursing interventions.

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

c) Urine output 100 ml

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) "You may continue to post about a client, as long as you do not use the client's name." b) "All aspects of clinical practice are confidential and should not be discussed." c) "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." d) "Any information that can identify a person is considered a breach of client privacy."

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

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) "It would be easier to do it that way. You could develop a tool to use." b) "The facility requires us to document client care this way because of the computer application used." c) "The electronic health record we use does not allow us to use different formats." 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 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) "I am concerned that the client might be exhibiting sepsis." b) "The client's temperature has been 102°F (38.9°C) for the last 6 hours." c) "The client was admitted today with a urinary tract infection." d) "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

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

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? a) Occurrence report and critical pathway. b) Critical pathway and care plan. c) Care plan and client's record. d) Client's record and occurrence report.

d) Client's record and occurrence report.

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

d) It provides quick access to abnormal findings.

The nurse is documenting care for a client with diabetes. Which nursing documentation will The Joint Commission review? Select all that apply. a) Nursing care provided b) Physical assessment c) Method of payment d) Nursing diagnoses e) Client teaching

a) Nursing care provided b) Physical assessment d) Nursing diagnoses e) Client teaching

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) "Only authorized persons are allowed to access client records." c) "The provider will need to give permission for you to review." d) "I am sorry I can't access that information."

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

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) What the client watched on television during the shift. b) What time the nurse will return for the next shift. c) Any abnormal occurrences with the client during the shift. d) Identifying demographics, including diagnosis. e) Current orders.

c) Any abnormal occurrences with the client during the shift. d) Identifying demographics, including diagnosis. e) Current orders.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? a) "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." b) "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 in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." d) "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

a) "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."

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? a) Review the hospital's process for allowing clients to view their health care records. b) Access the health care record at the bedside and show the client how to navigate the electronic health record. c) Discuss how the hospital can be fined for allowing clients to view their health care records. d) Explain that only a paper copy of the health care record can be viewed by the client.

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

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? a) Subjectivity b) Objectivity c) Organization d) Reimbursement

a) Subjectivity

Which statement regarding FOCUS charting is most accurate? a) The charting focuses on client strengths, problems, or needs. b) The charting focuses on the injury or illness only. c) Problem, intervention, evaluation (PIE) charting is used with FOCUS charting. 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 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 declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? a) Those directly involved in the client's care. b) Any family member of the client. c) Close friends of the client. d) Health care professionals of the facility.

a) Those directly involved in the client's care.

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? a) Write a narrative note in the designated nursing section. b) Place the narrative note chronologically after the respiratory therapist's note. c) Review the laboratory results under the physician section. d) Use a critical pathway to document the physical assessment.

a) Write a narrative note in the designated nursing section.

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 allow for us to see the client and possibly increase client participation in care." c) "It makes our client feel like we care, especially if we start the day off with a clean room." d) "It will give me a better sense of what my workload will be today."

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

HIPAA allows incidental disclosures of client health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of client health information. What are examples of this type of client health information disclosure? Select all that apply. a) The nurse uses sign-in sheets that contain information about the reason for the client visit. b) A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. c) The nurse uses white boards on an unlimited basis. d) The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. e) The nurse calls out names in the waiting room, but does not disclose the reason for the client visit. f) The nurse leaves a detailed appointment reminder message on a client's voice mail.

b) A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. d) The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. e) The nurse calls out names in the waiting room, but does not disclose the reason for the client visit.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate? a) Verify the insurance coverage before giving information. b) Explain the reason why information cannot be disclosed. c) Refer the parent to the physician providing care. d) Mediate a meeting between the parent and client.

b) Explain the reason why information cannot be disclosed.

Which statement is not true regarding a medication administration record (MAR)? a) The MAR distinguishes between routine and "as needed" medications. b) If the client declines the dose, the nurse does not have to document this on the MAR. c) The MAR identifies routine times for medication administration. d) After using an electronic MAR, the nurse should log off.

b) If the client declines the dose, the nurse does not have to document this on the MAR.

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 gives clients the right to withhold the release of their information to anyone. b) Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. c) 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 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.

c) 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 reports that on a scale of 0 to 10, the current pain is a 3. d) The client appears to have a low tolerance for pain and frequently reports intense pain.

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

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

c) Translators may need additional explanations of medical terms.

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) "This client has a medical history of heart failure." c) "It seems like this client has fluid volume overload." d) "I think the client would benefit from intravenous furosemide."

d) "I think the client would benefit from intravenous furosemide."

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: a) Need to obtain legal representation to update their health records. b) Can be punished for violating guidelines. c) Are required to obtain health record information through their insurance company. d) Have the right to copy their health records.

d) Have the right to copy their health records.

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 allows for you to change any information." c) "According to HIPAA legislation, you have a right to request changes to inaccurate information." d) "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."

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) One U of glucose c) 1 Unit of glucose d) 1U of glucose

c) 1 Unit of glucose