Ch. 38-2 Exemplar
The nurse reviews a facility's documentation techniques with a new nurse. Which statement should the nurse include? (Select all that apply.) A. "Document the client's responses to interventions." B. "Do not document the client's actual words." C. "Document in a timely manner." D. "Follow organizational policies to correct charting errors." E. "Use subjective and thorough descriptions."
"Document the client's responses to interventions." "Document in a timely manner." "Follow organizational policies to correct charting errors." Rationale: The nurse should document clients' responses to interventions, follow organizational policies to correct charting errors, and document in a timely manner. The nurse should document clients' actual words, placing quotation marks around client statements. Documentation should be objective, not subjective.
A healthcare provider prescribes an antibiotic by way of telephone order to treat an upper respiratory infection. After hanging up the phone and charting the order, the nurse notices that the client is taking another medication that will interact with the antibiotic. Which action should the nurse take? A. Administering the medications because the client is obviously having trouble breathing B. Ignoring the telephone order and deleting it from the chart because it hasn't been signed yet C. Clarifying the telephone order with the healthcare provider D. Notifying the charge nurse about the concern
Clarifying the telephone order with the healthcare provider Rationale: The nurse needs to communicate information about drug interactions and other contraindications to the healthcare provider giving the telephone order and seek clarification. Administering the new order when there is a known interaction violates the nurse's responsibility toward the client. Notifying the charge nurse passes the buck to someone else when the nurse knows that the interaction is potentially fatal and has a duty to do no harm. Deleting the telephone order, once given, is wrong because it is a valid order, even if it requires a signature within a specified time frame.
While logging into the bedside computer system to document in a client's medical record, the nurse is asked to help with another immediate issue. Which action should the nurse take? A. Leaving to help with the immediate issue B. Placing notes to be documented under the keyboard C. Explaining to the client the reason to leave the room D. Logging out of the system before responding to the pressing request
Logging out of the system before responding to the pressing request Rationale: To ensure the confidentiality and security of electronic records, the nurse must not leave a computer terminal unattended after logging into the system. The nurse should log out of the system before leaving the area. The nurse should not leave notes unattended under the computer keyboard, which could result in the inappropriate sharing of the client's PHI. The nurse may explain the reason for leaving the bedside after logging out of the system and before leaving to help with the other issue.
Which information should be included as handoff information for new client admissions? A. Comprehensive medical history, date of surgery, and therapies within the preceding 72 hours B. Reason for admission and diagnosis, date of surgery, and diagnostic tests and therapies within the last 24 hours C. Reason for admission and diagnosis, date of surgery, and therapies within the last 72 hours D. Comprehensive medical history and diagnostic tests and therapies within the last 24 hours
Reason for admission and diagnosis, date of surgery, and diagnostic tests and therapies within the last 24 hours Rationale: Handoff information must be concise, relevant, and targeted to care. It must include the reason for admission and diagnosis, date of surgery, and diagnostic tests and therapies within the last 24 hours. It is unrealistic and inappropriate to include comprehensive medical history during a handoff report.
The student nurse doing a clinical rotation needs to access client information for an assignment at school. For which reason should a student nurse have access to client information? (Select all that apply.) A. Writing papers B. Participating in clinical rounds C. Studying for exams D. Presenting client studies E. Presenting at clinical conferences
Writing papers Participating in clinical rounds Presenting client studies Presenting at clinical conferences Rationale: Student nurses are allowed access to client information for written papers, clinical rounds and conferences, and client studies. Access to client information for use as study materials is not appropriate for the student nurse.
The nursing staff at a women's health clinic uses the charting-by-exception method for appointments with regular clients. Which entry should the nurse document when following this method? A. Group B strep test negative B. Stretch marks on bilateral flanks in 20th week of pregnancy C. Fetal heart rate 200 with late decelerations D. IUD still in proper position; no side effects noted
fetal heart rate 200 with decelerations Rationale: In charting by exception, abnormal or unexpected changes in condition are noted. A normal fetal heart rate is 120dash160 beats/minute. Late decelerations with tachycardia signal fetal distress and oxygen deprivation caused by contractions or cord compression. A negative group B strep result, a contraceptive device that remains in place with no side effects, and skin changes noted in the 20th week of pregnancy are all expected findings that would not be noted under the charting-by-exception method.
The nurse is participating on a committee that will select a universal nursing documentation system for the hospital. Which advantage should the committee consider when looking at the focus charting documentation format? (Select all that apply.) A. Allows use of checklists or flow sheets to record routine nursing tasks B. Ensures that the nursing-focused assessment is the priority of care C. Provides a complete perspective of the client and the client's care needs D. Provides a structure for the progress notes E. Ensures that each progress note includes data, action, and the response
Allows use of checklists or flow sheets to record routine nursing tasks Provides a complete perspective of the client and the client's care needs Provides a structure for the progress notes Rationale: Focus charting makes the client and the client's concerns and strengths the focus of care. This charting system should provide a complete perspective of the client's care needs, along with the progress notes, and also record nursing tasks in the form of checklists or flow sheets. The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR. A note does not have to have all three categories. Focus charting is not the nurse's focused assessment.
During handoff communication, the condition of one client to be discussed has changed and needs immediate attention. Which action should the nurse take? A. Walk to the client's room together to address the client's need. B. Skip the handoff for the client. C. Find another nurse to attend to the client. D. Ask the nurse coming off duty to address the client's need and report the issues during handoff.
Ask the nurse coming off duty to address the client's need and report the issues during handoff. Rationale: Until the shift has actually changed and a handoff has been made, the nurse who is about to leave is still responsible for the client's well-being and needs to attend to the concern, whether it is emergent or routine. Therefore, assessing, intervening, and noting unusual findings in the report would be the most appropriate step. Skipping the handoff, walking to the client's room together to address the client's need, and asking another nurse to attend to the client are inappropriate.
Which step should the nurse take when completing a telephone order? (Select all that apply.) A. Reading the order back to the healthcare provider B. Writing "20 U insulin given daily subcutaneously at 1800" C. Writing the complete order down D. Accepting a voice-mail order E. Identifying it as a verbal order or telephone order
reading the order back to the healthcare provider Writing the complete order down Identifying it as a verbal order or telephone order Rationale: Writing the complete order down, identifying it as a verbal order (VO) or telephone order (TO), and reading it back to the healthcare provider to ensure that it is accurate are the steps when taking a telephone order. Writing detailed information about dosage is required, but this order should have been written as "20 units," not "20 U." The nurse must never accept a voice-mail order.
The nurse is preparing to provide an oral change-of-shift report on assigned clients. Which piece of information should be included in this report? (Select all that apply.) A. Information about clients who were discharged B. Changes in the clients' conditions C. Any client's needs for emotional support D. Name of the prescribing healthcare provider E. Clients' baseline vital signs and nursing interventions
Information about clients who were discharged Changes in the clients' conditions Any client's needs for emotional support Rationale: When providing a change-of-shift report, the nurse should report changes in clients' condition, any client's needs for emotional support, and information about clients who have been transferred or discharged. Information about prescribing healthcare providers and clients' baseline vital signs is available in the clients' medical records.
Which action should the nurse avoid when documenting data in a client's medical record? (Select all that apply.) A. Leaving blank lines B. Charting for someone else C. Altering an entry D. Using objective descriptions E. Using vague terms
Leaving blank lines Charting for someone else Altering an entry using vague terms Rationale: It is inappropriate to alter an entry, leave blank lines, use vague or general terms, or chart for someone else. Objective descriptions should be used.
A healthcare organization uses the problem-oriented medical record (POMR) system for documenting client care. Which individual should be identified as responsible for generating the plan of care once a client problem has been identified? A. Nurse or healthcare provider identifying the problem B. Primary care provider for the client C. Nurse assigned to the client for that shift D. Manager or charge nurse for the unit
Nurse or healthcare provider identifying the problem Rationale: The care plan is generated by the nurse or healthcare provider who listed the problem on the problem list. Primary care providers identify the plan of care with orders or medical care plans. Nurses write nursing orders or care plans. The manager or charge nurse would create the plan of care, depending on who identified the client problem.
The nurse is reviewing the organization's policy on handoff communication and the use of the SHARE method with a group of new nurses. Which piece of information regarding this method should the nurse emphasize? (Select all that apply.) A. Provides standardized training in the handoff process B. Ensures that the nurse uses personal narrative and charting during the transfer C. Provides an opportunity to ask questions during the transfer D. Provides timely feedback to staff who fail to follow the process E. Ensures that the nurse provides the essential content during the transfer
Provides standardized training in the handoff process Provides an opportunity to ask questions during the transfer Provides timely feedback to staff who fail to follow the process Ensures that the nurse provides the essential content during the transfer Rationale: One strategy for ensuring a successful handoff is the SHARE method. This ensures that all essential content is provided during the transfer. It provides standardized training and the opportunity to ask questions during the transfer. Feedback is also provided for those who fail to follow the process. This process does not require the nurse to use a personal narrative and charting during the transfer.
The nurse needs to send a fax containing a client's protected health information (PHI) to another healthcare facility. Which action should the nurse take to protect the client's PHI? (Select all that apply.) A. Ensuring that PHI is contained in the transmittal B. Requiring the receiving agency to send a signed receipt C. Obtaining consent from the client to fax the information D. Using a cover sheet with a disclaimer statement E. Verifying the fax number before sending the information
Requiring the receiving agency to send a signed receipt Obtaining consent from the client to fax the information Using a cover sheet with a disclaimer statement Verifying the fax number before sending the information Rationale: Faxing of confidential information is a privacy concern in healthcare. Security measures to follow when faxing PHI include using a cover sheet with a disclaimer statement, requiring the receiving agency to send a signed receipt, obtaining consent from the client to fax PHI, and checking the fax number before sending the fax. The nurse should remove personally identifiable information from the transmittal to protect the client's privacy.
The nurse accesses a client's database within the problem-oriented medical record (POMR). Which client information should the nurse document in this area? A. Plan of care B. Spiritual needs C. Health history D. Nursing diagnosis
health history Rationale: The database of a POMR consists of all information known about the client when the client first enters the healthcare agency, including the client's health history. The spiritual needs of the client and the nursing diagnosis are documented in the problem list of the POMR. The plan of care has its own section in the POMR.
Which piece of information should the nurse document in a progress note in the focus charting system? (Select all that apply.) A. Response B. Standards C. Data D. Problems E. Action
response data action Rationale: Progress notes are organized into (D) data, (A) action, and (R) response: DAR. Data (D) refers to the assessment phase of the nursing process and includes both subjective and objective data. Action (A) is the planning and implementation phases of the nursing process and includes immediate and future nursing actions and any changes to the plan of care. Response (R) is the evaluation phase of the nursing process and describes the client's response to any nursing and medical care. Problems are part of the PIE model of documentation. Standards are part of the charting-by-exception documentation method.
The nurse manager observes a new nurse receive a prescription for a new medication by telephone. For which action should the nurse manager intervene? (Select all that apply.) A. Questioning dosages, medications, and potential interactions that seem inappropriate B. Signing the healthcare provider's name to the order C. Saying, "Doctor, slow down! How am I supposed to understand you?" D. Signing name to indicate who received the order E. Recording the time and date and that it was a telephone order
signing the healthcare provider's name to the order Saying, "Doctor, slow down! How am I supposed to understand you?" Rationale: The nurse's name is signed to indicate that the order was received. The nurse records the time and date and notes that it was a telephone order. Medications, dosages, and interactions that seem inappropriate should be questioned. Telling the healthcare provider to slow down is inappropriate and disrespectful. The nurse does not have the authority to sign for the healthcare provider and must follow agency policy for submitting the order back to the healthcare provider for a signature.
Which question should the nurse ask the healthcare provider to verify the medication when taking a medication prescription by phone? (Select all that apply.) A. "Did you say 15 mL an hour or 50 mL an hour for the IV fluids?" B. "Can you ask your secretary to put this order in the computer?" C. "Can I read this order back to you before you hang up?" D. "Will you please repeat the type of IV fluids?" E. "Can you please speak a little slower?"
"Did you say 15 mL an hour or 50 mL an hour for the IV fluids?" Can I read this order back to you before you hang up?" "Will you please repeat the type of IV fluids?" "Can you please speak a little slower?" Rationale: The nurse should question the healthcare provider about any medication prescription that is ambiguous, including the name of the medication or dosage. While taking the telephone order, the nurse should write it down or enter it into the computer, then read the order back to the healthcare provider. Either the healthcare provider or the nurse must put the order in the computer; the healthcare provider must later cosign the order. The healthcare provider should speak slowly and clearly so that the nurse can understand the order and record it correctly.
The nurse at a residential treatment facility is preparing a telephone report about a client for an emergency department. Which statement should the nurse make? A. "The client was found unconscious in her room, and an empty Tylenol bottle was found near her." B. "I'm not sure about the pills the client took. She's unconscious." C. "I don't have my chart handy, but the client's vital signs have been pretty stable until now." D. "I can't believe the mother would give a bottle of Tylenol to someone in detox on suicide watc
"The client was found unconscious in her room, and an empty Tylenol bottle was found near her." Rationale: Telephone reports must remain factual and provide all relevant information needed to treat the client. Vital signs, possible toxin, Glasgow Coma Score rating, and time of the precipitating incident are pertinent information. The nurse should have the chart handy in case the dispatcher or physician asks for more information. Conversational points such as speculation or opinions distract providers from the necessary information being passed along and must be avoided.
Which mnemonic should the nurse identify as correct for SBAR? A. State of the client, background, assessment, remediation B. State of the client, behaviors, actions, recommendation C. Situation, behaviors, actions, remediation D. Situation, background, assessment, recommendation
Situation, background, assessment, recommendatio Rationale: SBAR stands for situation, background, assessment, and recommendation. It is a method of organizing information at handoffs. The other choices incorrectly explain the mnemonic SBAR.
