PrepU Chp.9

During rounds, the nurse finds that a client with paralysis has fallen from the bed because the nursing assistant failed to raise the side rails after giving the client a bath. The nurse assists the client back to bed and performs an assessment of the client for injury. As per the agency policies, the nurse fills out an incident report. Which of the following would be most appropriate for the nurse to do? a) Include time and date of the incident on the form b) Attach a copy of the incident report to the client's records c) Mention the name of nursing assistant in client records d) Highlight the incident in the client's records as involving an error

a) Include time and date of the incident on the form

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: a) Limiting abbreviations to those approved for use by the institution. b) Using only those abbreviations that are defined in full at another location in the client's chart. c) Ensuring that abbreviations are understandable to clients who may seek access to their health records. d) Using only abbreviations whose meaning is self-evident to an educated health professional.

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

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

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

Which of the following data entries follows the recommended guidelines for documenting data? a) "Client's kidneys are producing sufficient amount of measured urine." b) "Following oxygen administration, vital signs returned to baseline." c) "Client is overwhelmed by the diagnosis of pancreatic cancer." d) "Client complained about the quality of the nursing care provided on previous shift."

b) "Following oxygen administration, vital signs returned to baseline."

A nurse uses the computer to access health records of the clients. What care should the nurse take when using a computer to access health records? a) The password and access number should be shared only with the client. b) The password and access number should be kept secret and changed regularly. c) The password and access number should be shared only with the auditors. d) The password and access number should be shared only with the physician.

b) The password and access number should be kept secret and changed regularly.

A patient asks to see his medical record (chart). How would the nurse respond? a) "I can't let you do that without a doctor's order." b) "Our hospital policy is that you can't do that." c) "I will get your chart and provide you with privacy to read it." d) "Why would you want to do that? It will only make you worry."

c) "I will get your chart and provide you with privacy to read it."

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report? a) Client's intake for previous meal b) Client's family members c) Current client assessment d) Client's admission number

c) Current client assessment

A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality? a) Providing information to the physician about laboratory data b) Providing the instructor with plans for care c) Writing the client's name on the student care plan d) Discussing the medications with a unit nurse

c) Writing the client's name on the student care plan

What is the primary purpose of the patient record? a) advocacy b) research c) education d) communication

d) communication