Nurs 232 PREP -U ASSIGNMENT : Documenting and reporting

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart.

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?

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

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error?

Create an addendum with a correction.

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?

Incident report

Which principle should guide the nurse's documentation of entries on the client's health care record?

Precise measurements should be used rather than approximations

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?

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

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?

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

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

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

reporting

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?

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 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

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take?

Revise the plan of care

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?

Use minimum disclosure policy to release the information

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

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

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

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

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."

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?

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

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

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

subjectivity