chapter 16 craven questions

When documenting client care, which principles should the nurse strive for? Select all that apply. -Subjectivity -Confidentiality -Accuracy -Objectivity -Timeliness

confidentiality accuracy objectivity timeliness

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." - "No, the physician will not give you access to review the records." - "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

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? -Disclosing client health information for research purposes after obtaining permission from the client's physician -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 -Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

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

Which is not a purpose of the client care record? -To serve as a legal document - To facilitate reimbursement -To serve as a contract with the client -To assist with care planning

to serve as a contract with the client

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

interpretation of data

A nurse is giving the change-of-shift report on a client who has just returned from surgery. What client information should the nurse include in the report? Select all that apply. - name of the client - intake and output prior to surgery - client discharge teaching needs - type of insurance - personal feelings about the client -current vital signs

name of the client intake and output prior to surgery client discharge teaching needs current vital signs

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

"Clipboards with client data should not leave the unit."

Which abbreviation is correct for use in documentation? -PO -Sub q -Per os -BT

PO

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? - 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

a client who is homebound and needs skilled nursing care

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? -Notifying the nursing team of the client's condition -Documenting client data on the flow sheet - Keeping an accurate medication record - Accurately documenting client care on the client record

accurately documenting client care on the client record

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

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

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? -The client is receiving sufficient relief from pain medication, stating no pain in either knee. -The client appears comfortable and is resting adequately and appears to not be in acute distress. -The client reports that on a scale of 0 to 10, the current pain is a 3. -The client appears to have a low tolerance for pain and frequently reports intense pain.

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

When documenting client care in the client's health record, which abbreviations would be appropriate for the nurse to use? Select all that apply. - D/C -per os - PO - mL -cc

PO mL

Which actions should the nurse take before making an entry in a client's record? Select all that apply. -Reviewing the agency's list of approved abbreviations -Choosing the charting format that the nurse prefers -Locating clients' files within an electronic health record system -Identifying the form appropriate to be used for documenting -Checking that clients' names are not identified within the chart forms

Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider? - eMAR -SOAP -SBAR -CBE

SBAR

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting? -charting by exception (CBE) -FOCUS charting problem, intervention, evaluation (PIE) charting - variance charting

charting by exception CBE

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? -"I am calling because the client receiving blood has developed dyspnea and had crackles." - "This client has a medical history of heart failure." - "It seems like this client has fluid volume overload." -"I think the client would benefit from intravenous furosemide."

i think the client would benefit from intravenous fuosemide

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

it provides quick access to abnormal findings

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? - "The benefit of CBE is that it demonstrates whether high-quality care is given." -"CBE is the best way to protect against lawsuits." - "CBE is a relatively new format of documentation in electronic health records." -"The benefit of CBE is less time needed on computer charting."

the benefit of CBE is less time needed on computer charting

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality? -providing the instructor with plans for care - discussing the medications with a unit nurse - providing information to the physician about laboratory data -writing the client's name on the student care plan

writing the clients name on the student care plan

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

- "According to HIPAA legislation, you have a right to request changes to inaccurate information."

The nurse's morning assessment of an older adult client has revealed some anomalies. The nurse should document the client's abnormal heart rate as: -"115 beats per minute" - "Unusually fast" - "Tachycardic" - "Outside baselines"

115 beats per minute

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider? -SBAR - eMAR -SOAP -CBE

SBAR

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? -Disclosing client health information for research purposes after obtaining permission from the client's physician -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 -Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

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

Which are examples of breaches of client confidentiality? Select all that apply. -A nurse discusses information about a client with a coworker in the elevator. - A nurse shares his or her computer password with another nurse who was unable to log in to the system. - A nurse checks the health record of a client to see who is the contact person for an emergency. - A nurse updates the employer of a client regarding the client's date of return to work. - A nurse uses a computer to document a client's response to pain medication.

-A nurse discusses information about a client with a coworker in the elevator. -A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse updates the employer of a client regarding the client's date of return to work.

Which are examples of breaches of client confidentiality? Select all that apply. -A nurse discusses information about a client with a coworker in the elevator. -A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse checks the health record of a client to see who is the contact person for an emergency. -A nurse updates the employer of a client regarding the client's date of return to work. -A nurse uses a computer to document a client's response to pain medication.

-A nurse discusses information about a client with a coworker in the elevator. -A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse updates the employer of a client regarding the client's date of return to work.

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

interpretation of data

A nurse is preparing to document information about a client using the FOCUS system. Which information would the nurse record in the action section? -objective data -interventions -subjective data -effect of action on client

interventions

Which is a drawback to the type of documentation known as charting by exception? -Interference with standardized assessments -Less interdisciplinary communication - Issues related to high-quality care should a negligence claim arise -Increased time required to document information

issues related to high quality care should a negligence claim arise

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying what as the first step? -plan of care - data, action, and response -problem selected -nursing activities during a shift

problem selected

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? -"No medical issues overnight that require immediate attention." -"The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." -"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." -"The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety."

the client had a good deal of anxiety last night and requested to be turned and repositioned frequently

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? -The provider can input orders remotely into the EHR system for the nurse to retrieve. -The nurse can implement care once written orders are received from the provider. -The nurse can accept verbal orders to provide immediate care and record once the client is stable. - The client must be stabilized before the nurse can obtain any orders from the provider.

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

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 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. - 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

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

a flow sheet

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: -have the right to copy their health records. -need to obtain legal representation to update their health records. - can be punished for violating guidelines. -are required to obtain health record information through their insurance company.

have the right to copy their health records

The nurse is documenting care for a client with diabetes. Which nursing documentation will The Joint Commission review? Select all that apply. -nursing care provided - physical assessment -method of payment -nursing diagnoses - client teaching

nursing care provided physical assessment nursing diagnoses client teaching

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawback? -vulnerability to legal liability since nurse's safe, routine care is not recorded - increased workload for nurses in order to complete necessary documentation - failure to identify and record client problems and associated interventions -significant differences in the charting between nurses due to lack of standardization

vulnerability to legal liability since nurses safe routine care is not recorded

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry? -"Client is guarding her abdomen and occasionally moaning." -"Client has a history of recent abdominal pain." -"Client is reporting that her abdominal pain is rated at 8/10." -"2 mg hydromorphone hydrochloride PO was administered with good effect."

-"Client is reporting that her abdominal pain is rated at 8/10."

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? -A never event - A variance - An audit -A sentinel event

a variance

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? -Fill out an incident report. - Attach a copy of the incident report to the chart. - Stop the infusion and document the time. -Report the error to the primary provider.

attach a copy of the incident report to the chart

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? -SOAP - narrative -focus -charting by exception

charting by exception

Which method of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? -problem-oriented medical record - charting by exception -PIE charting system -FOCUS charting

charting by exception

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

the client reports waking up this morning with a severe headache

A nurse in the intensive care unit has just reported for duty. A client is being transferred to the medical floor after change of shift. Which action would the nurse take to ensure maximum efficiency of change-of-shift or transfer reports? -Call the receiving nurse with a list of the client's medication. ​ -Ask the health care provider to provide transfer report to the receiving nurse. -Print the client's medical record to accompany the client during transfer. -Utilize the electronic medical record while providing report to the receiving nurse.

utilize the electronic medical record while providing report to the receiving nurse

Which are appropriate actions for protecting clients' identities? Select all that apply. -Orient computer screens toward the public view. -Ensure that clients' names on charts are visible to the public. -Document all personnel who have accessed a client's record. - Place light boxes for examining X-rays with the client's name in private areas. -Have conversations about clients in private places where they cannot be overheard.

-Document all personnel who have accessed a client's record. -Place light boxes for examining X-rays with the client's name in private areas. -Have conversations about clients in private places where they cannot be overheard.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider? -SBAR -eMAR -SOAP -CBE

SBAR

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? - "I am concerned that the client might be exhibiting sepsis." - "The client's temperature has been 102°F (38.9°C) for the last 6 hours." - "The client was admitted today with a urinary tract infection." - "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

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

Which are examples of breaches of client confidentiality? Select all that apply. -A nurse discusses information about a client with a coworker in the elevator. - A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse checks the health record of a client to see who is the contact person for an emergency. -A nurse updates the employer of a client regarding the client's date of return to work. - A nurse uses a computer to document a client's response to pain medication.

-A nurse discusses information about a client with a coworker in the elevator. - A nurse shares his or her computer password with another nurse who was unable to log in to the system. - A nurse updates the employer of a client regarding the client's date of return to work.

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawback? -vulnerability to legal liability since nurse's safe, routine care is not recorded - increased workload for nurses in order to complete necessary documentation - failure to identify and record client problems and associated interventions - significant differences in the charting between nurses due to lack of standardization

vulnerability to legal liability since nurses safe, routine care is not recorded

A nurse is preparing to document information about a client using the FOCUS system. Which information would the nurse record in the action section? -objective data - interventions - subjective data - effect of action on client

interventions

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. -The nurse uses sign-in sheets that contain information about the reason for the client visit. - A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. -The nurse uses white boards on an unlimited basis. -The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. -The nurse calls out names in the waiting room, but does not disclose the reason for the client visit. - The nurse leaves a detailed appointment reminder message on a client's voice mail.

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

Which are examples of breaches of client confidentiality? Select all that apply. -A nurse discusses information about a client with a coworker in the elevator. - A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse checks the health record of a client to see who is the contact person for an emergency. - A nurse updates the employer of a client regarding the client's date of return to work. -A nurse uses a computer to document a client's response to pain medication.

-A nurse discusses information about a client with a coworker in the elevator. -A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse updates the employer of a client regarding the client's date of return to work.

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

Which is the proper way to document midnight in a client's record? -0000 -2401 -1200 -1201

0000

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? - SOAP - PIE -MAR -SBAR

SBAR

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details? -FOCUS charting -narrative charting -PIE charting -SOAP charting

SOAP charting

A nurse is working as part of a team that is presenting an in-service to the staff on the TeamSTEPPS program. Which skills would the nurse expect to be addressed as part of this program? Select all that apply. -Team leadership - Communication -Situational monitoring - Mutual support - Checklist completion - Flow chart development

Team leadership Communication Situational monitoring Mutual support

Which part of the client's record is commonly used to document specific client variables, such as vital signs? -progress notes - nursing notes - critical paths -flow sheets

flow sheet

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest? -charting by exception - narrative notes -problem, intervention, and evaluation note -FOCUS data, action, and response note

charting by exception

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

following oxygen administration vital signs returned to baseline

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

limiting abbreviations to those approved for us by the institution

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

limiting abbreviations to those approved for use by the instituion

A nurse charting the health care record for a client knows that which form of charting involves writing information about the client and client care in chronological order? -FOCUS charting -SOAP charting - narrative charting -PIE charting

narrative charting

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? - "The care plan is the only way for nurses to document what they do." - "The care plan provides additional documentation about the work of the nurse." - "The care plan shows the medical diagnosis for the client." -"The care plan is required for every client by The Joint Commission."

the care plan is required for every client by the joint commission

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 is coughing and experiencing severe heartburn in the morning. -The client has a history of severe complaints in the morning.

the client reports waking up this morning with a severe headache

Which finding from a nursing audit reflects high standards for client safety and institutional health care? -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. -The nurse fails to adequately complete data on clients' health histories and discharge planning.

the nurse documents clients responses to nursing interventions

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

- It provides quick access to abnormal findings.

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

-"Following oxygen administration, vital signs returned to baseline."

The nurse is tasked to organize weekly care plan conferences with other health care team members. Which would be appropriate items to include in this meeting? Select all that apply. -A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made - A review of a client's current progress in the plan of care -A discussion of the meal plan for a client with diabetes -A recommendation for pain management by the emergency department physician who admitted the client a week ago - A conversation addressing the need for durable medical equipment when the client goes home

-A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made -A review of a client's current progress in the plan of care -A discussion of the meal plan for a client with diabetes -A conversation addressing the need for durable medical equipment when the client goes home

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 - SOAP charting -PIE 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? -FOCUS charting -SOAP charting -PIE charting -narrative charting

SOAP charting

A nurse is making a home visit to a client for the first time. The nurse is documenting assessment information on a laptop computer as each aspect of the assessment is completed. The nurse is using: -computerized provider entry order. - just-in-time documentation. -point-of-care documentation. - batch charting.

point of care documentation

A client with hemiplegia has been admitted to the health agency. The nurse who cares for the client has a fixed routine of cleaning, feeding, and administering medicines to the client. Which should the nurse use to record these details? -checklists -flow sheet - nursing Kardex -nursing care plan

checklist

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which is an example of a written form of communication? -notepad -e-mail -checklist -SMS

checklist

The nurse is assessing a client's postoperative pain. Which statement demonstrates accurate documentation of objective pain assessment? -"Client does not appear to be in pain." -"Client is smiling and talking with visitors—pain scale not used." -"Client seems irritated but states pain is around a level 5." -"Client rates pain 4 on a scale of 0 to 10."

client rates pain 4 on a scale of 0 to 10

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 expecting some pain, but it is more severe than anticipated. -Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. -Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." -Client is requesting pain medications, is grimacing, and is diaphoretic.

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 in the intensive care unit who must be administered multiple medications. The client is often unresponsive and cannot offer information during assessment. When administering the medication, which step by the nurse is most important to avoid confusion and ensure safety? -Identify the client by the wristband at least twice before administering the medication if the client is unresponsive, once upon entering the room and then prior to administration. -Scan the client's wristband prior to administering medication to verify it is the correct client and correct medication. -Identify the client by asking the spouse or other family members present if the client is unresponsive, ensuring to obtain the full name and date of birth. -Compare the client's wristband to the eMAR and EHR information if the client is unresponsive, then verify the medication has the same identifying information.

compare the clients wristband to the eMAR and EHR information if the client is unresponsive then verify the medication has the same identifying information

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? -client assessment -intervention carried out -written plan of care -multidisciplinary interventions

intervention carried out

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal? -narrative notes -SOAP notes -FOCUS charting - charting by exception

narrative notes

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

flow sheet

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? -gauging the nurse's professional performance over time -protecting the nurse and the hospital from litigation -identifying risks and ensuring future safety for clients -following up the incident with other members of the care team

identifying risks and ensuring future safety for clients

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? -identifying risks and ensuring future safety for clients -gauging the nurse's professional performance over time -protecting the nurse and the hospital from litigation -following up the incident with other members of the care team

identifying risks and ensuring future safety for clients

A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next? -Date it and put it in the client's record. - Sign it and put it in the Kardex. - Individualize it to the specific client. -Use it as printed, based on common needs.

individualize it to the specific client

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? - client assessment -intervention carried out - written plan of care -multidisciplinary interventions

intervention carried out

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation? -Source-oriented -Problem-oriented - PIE charting -Charting by exception

source oriented

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? -"The clients' medical records provide data for legal evidence." - "I can share the clients' medical records with the health care team." - "The clients' medical records are an obstruction to research and education." - "The clients' health records should be used to promote reimbursement from insurance companies"

the clients medical records are an obstruction to research and education

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? -"The clients' medical records provide data for legal evidence." -"I can share the clients' medical records with the health care team." -"The clients' medical records are an obstruction to research and education." -"The clients' health records should be used to promote reimbursement from insurance companies"

the clients medical records are an obstruction to research and education

Which is not a purpose of the client care record? - To serve as a legal document - To facilitate reimbursement -To serve as a contract with the client - To assist with care planning

to serve as a contract with the client

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. -Use minimum disclosure policy to release the information. -Refer the insurance agency directly to the client. -Release the full medical record to expedite payment.

use minimum disclosure policy to release the information

Which documentation by the nurse best supports the PIE charting system? - States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given - Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg - Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea -Vomiting 250 mL undigested food, antiemetic given, no further vomiting

vomiting 250 mL undigested food antiemetic given no further vomiting

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which clinical situation? -when communicating a client's change in condition to the client's physician - when providing a change-of-shift report to a colleague -when documenting the care that was provided to a client whose condition recently deteriorated -when reporting to a client's family member or significant other

when communicating a clients change in condition to the clients physician

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality? -writing the client's name on the student care plan -providing the instructor with plans for care -discussing the medications with a unit nurse -providing information to the physician about laboratory data

writing the clients names on the students care plan