Week 2 - Chapter 19: Documenting and Reporting

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? 0930 2130 930 p.m. 1930

2130

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? Transfer report Nurse's shift report Telemedicine report Incident report

Incident report

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 a client whose rehabilitation potential is not good a client whose status is stabilized a client who is not making progress in expected outcomes of care

a client who is homebound and needs skilled nursing care

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

Subjective data should be included when documenting.

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

The lower extremities

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

The nurse documents clients' responses to nursing interventions.

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

a

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

a

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. a. Conversations about clients must take place in private places where they cannot be overheard. b. The names of the clients on charts should be visible to the public. c. Documentation must be kept of personnel who have accessed a client's record. d. Light boxes for examining X-rays with the client's name must be in private areas. e. Computer screens must be oriented toward the public view.

a, c, d

When documenting client care, for what principles of documentation is the nurse responsible? Select all that apply. accuracy objective timely confidentiality subjective

confidentiality accuracy objective timely

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. Provide the information to the parent. b. Explain the reasons for the hospitalization, but give no further information. c. Take the parent to the client's room and have the client give the requested information. d. Ask the client if information can be given to the parent.

d

The client record is utilized for many purposes. Which might be uses for the client record? Select all that apply. education for medical students research education of student nurses giving information over the phone when unidentified callers call the hospital unit reimbursement for services

education of student nurses reimbursement for services research education for medical students

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? Occurrence report and critical pathway Client's record and occurrence report Critical pathway and care plan Care plan and client's record

Client's record and occurrence report

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?

00:00

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

a

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

a

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

c

A nurse is transfusing multiple units of packed red blood cells (PRBCs). 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? "This client has a medical history of heart failure." "It seems like this client has fluid volume overload." "I am calling because the client receiving blood has developed dyspnea and had crackles." "I think the client would benefit from intravenous furosemide."

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

The parents of a hospitalized child ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? "No, the physician will not give you access to review the records." "I will arrange access for you to review the record after you put your request in writing." "Are you questioning the care of your child?" "Only the client has the right to review the health care records."

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

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? Calling the client information desk to find out the room number of the family member Asking the emergency department nurse for information on the family member Finding the emergency medical technicians who transported the family members and inquiring about the injuries Accessing the electronic health record of the family member to find out extent of injury

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

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 CABG procedure will help increase intestinal motility and prevent constipation." "A complete ablation of the biliary growth will decrease liver inflammation." "The CABG procedure will help identify nutritional needs."

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

??? Place the narrative note chronologically after the respiratory therapist's note. Use a critical pathway to document the physical assessment. Write a narrative note in the designated nursing section. Review the laboratory results under the physician section.

Write a narrative note in the designated nursing section.

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

a

What ensures continuity of care? integration critical thinking communication reassessment

communication

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? data base plan of care problem list progress notes

progress notes

The client states, "I hate this place. I want to go home. No one listens to me, and my doctor has not been in to see me today." The client's arms are folded across his chest. His brow is furrowed, and he will not allow morning vital sign measurements. Which entry should be included in the nurse's charting? Select all that apply. unhappy with care will not allow morning vital sign measurements states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today" seems angry today arms folded across chest and brow is furrowed

arms folded across chest and brow is furrowed states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today" will not allow morning vital sign measurements

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

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

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 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."

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

The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr. The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastric pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method? 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 4 mg IV morphine every 4 hours 4/10 pain with nausea; on IV fluids NPO, 4/10 pain, epigastric pain, nausea 4/10 pain on pain scale, epigastric pain; with reports of nausea

4/10 pain on pain scale, epigastric pain; with reports of nausea

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

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? PIE charting method Problem-oriented method Focus charting method Source-oriented method

Problem-oriented method

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 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. 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.

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? Review the hospital's process 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. Discuss how the hospital can be fined for allowing clients to view their health care records.

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

Question 20 of 20 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 has a history of severe complaints in the morning. The client is coughing and experiencing severe heartburn 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, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. The nurse sends or directs someone to take action in a specific nursing care problem. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. 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.

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

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 PIE charting, even if it is not the institution's charting method. Use abbreviations approved by the facility. Document lengthy entries using complete sentences. Only document changes in the client's status.

Use abbreviations approved by the facility.

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? Do not release any information to the insurance company. Release the full medical record to expedite payment. Use minimum disclosure policy to release the information. Refer the insurance agency directly to the client.

Use minimum disclosure policy to release the information.

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? a. Calling the client information desk to find out the room number of the family member b. Finding the emergency medical technicians who transported the family members and inquiring about the injuries c. Accessing the electronic health record of the family member to find out extent of injury d. Asking the emergency department nurse for information on the family member

a

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

a flow sheet

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

b

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

b

Which statement is not true regarding a medication administration record (MAR)? a. The MAR identifies routine times for medication administration. b. If the client declines the dose you do not have to document this on the MAR. c. 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 the previous nurse's name by mistake. d.The MAR distinguishes between routine and "as needed" medications

b

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

c

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

c

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. 1930 b. 930 p.m. c. 2130 d. 0930

c

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

interpretation of data.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? recording appropriate nursing interventions identifying nursing diagnoses or clients' needs documenting clients' health histories and discharge planning omitting clients' responses to nursing interventions

omitting clients' responses to nursing interventions

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

urine output 100 ml

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? Explain the reasons for the hospitalization, but give no further information. Ask the client if information can be given to the parent. Take the parent to the client's room and have the client give the requested information. Provide the information to the parent.

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

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. Light boxes for examining X-rays with the client's name must be in private areas. Documentation must be kept of personnel who have accessed a client's record. The names of the clients on charts should be visible to the public. Conversations about clients must take place in private places where they cannot be overheard. Computer screens must be oriented toward the public view.

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. Conversations about clients must take place in private places where they cannot be overheard.

The nurse is caring for a client with uncontrolled hypertension. The client's blood pressure has remained controlled for the nurse's shift. At 2-hour intervals the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the client has a stroke. Years later, the client files a lawsuit blaming the hospital for the stroke. The nurse who was caring for the client when the blood pressure was stable cannot recall the exact blood pressure obtained, but remembers it was normal. Will this recollection suffice in court and why? Yes, the nurse was not on duty when the stroke occurred. No, if the blood pressure measurement was not documented, it did not happen. No, but it will relieve the nurse of any wrongdoing. Yes, the nurse remembers the pressure as normal during the shift and can swear to it during the deposition.

No, if the blood pressure measurement was not documented, it did not happen.

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

a

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? FOCUS charting PIE charting SOAP charting narrative charting

SOAP charting

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

a

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

a

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

b

To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information? 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 failing to recognize the client's right to withhold health information for research releasing the client's entire health record when only portions of the information are needed

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