Chapter 19: Documenting and Reporting (2)

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? pg. 459

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

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse? pg. 463-465

"I will have to review the policy that determines what procedure is in place for client access."

A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information? pg. 467

"You can fill in information from your own records and store it on your computer or the Internet."

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? pg. 456

Create an addendum with a correction.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: pg. 456

Interpreted data

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? pg. 463

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

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? pg. 459

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? pg. 453-456

The nurse documents clients' responses to nursing interventions.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: pg. 478

a referral.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? pg. 469

urine output 100 ml

In SBAR, what does R stand for? pg. 477

Recommendations

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? pg. 469

"The benefit of CBE is less time needed on computer charting."

Which statement is not true regarding a medication administration record (MAR)? pg. 471

If the client declines the dose, the nurse does not have to document this on the MAR.

Which example may illustrate a breach of confidentiality and security of client information? pg. 455

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

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): pg. 456

legal document.

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting? pg. 456

"If I make an error, I draw a single line through it and put my initials by it."

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? pg. 475

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

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? pg. 468

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 interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? pg. 469

subjectivity

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? pg. 455

those directly involved in the client's care