Exam 6 FlexiQuiz 2of2
"You can make extra money with overtime pay with end-of-shift charting."
The student nurse is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?
"I will log out of the electronic health record and you can log in to document."
The unlicensed assistive personnel (UAP) has taken vital signs. The nurse is currently logged into the electronic health record, and the UAP needs to document the vital signs. How does the nurse the UAP to document?
Place light boxes for examining x-rays with the client's name in private areas.
A nurse is caring for a client at the local health care facility. What ensures that the HIPAA legislation is implemented at the facility?
Assume a position at eye level with the client and continue with the interview.
A nurse is interviewing an American Indian client who has come to the clinic for a follow- up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?
Describe the type of metal and stones in the ring.
A nurse is taking a note of a client's belongings by recording their details in the medical record. How should the nurse best describe a client's ring?
summary of treatment started and current client condition
A nurse is transferring a client with myocardial infarction (MI) to a tertiary care center. What referral information is most important for the nurse to relay to the receiving nurse so the client receives appropriate follow-up care?
Therapeutic communication is focused on a particular goal while social communication is more superficial in content.
A nurse is working with an adult client who has been admitted with hyperglycemia following a period of poor glycemic control. The nurse has many similarities to the client with regard to age, gender, and socioeconomic status but is careful to utilize therapeutic communication techniques rather than social communication. How does therapeutic communication differ from social communication?
Approach the client from the front. Use the client's name. Smile and maintain eye contact.
A nurse needs to complete and assessment and vital signs on a client who has Alzheimer's disease. How should the nurse approach this client to gain cooperation? (Select all that apply.) A. Approach the client from the front. B. Use the client's name. C. Focus on the nursing tasks. D. Smile and maintain eye contact. E. Speak loudly and clearly.
"Clipboards with client data should not leave the unit."
A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?
Ensure that the client does not eat or drink anything
An elderly female client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician's orders and reads the order "NPO". Based on this order, what action should the nurse take?
immediately following administration
The nurse is caring for a client who is prescribed an antibiotic by mouth every 4 hours. When will the nurse document that the antibiotic has been given?
Sign each entry by name and title.
When documenting information in a client's medical record, what should the nurse do consistently for each entry?
To orient the client to the facility
A client admitted to the health care facility for minor surgery is given a booklet by the nurse about the health care facility. Which of the following is a purpose of this booklet?
every 3 month
A client admitted to the health care facility is assessed using a Minimum Data Set. How often is the Minimum Data Set repeated for a client?
Extended Care
A client has a diagnosis of stage 4 non-small cell lung cancer (NSCLC). The nurse consulted social services for discharge planning regarding appropriate level of care needed after chemotherapy. The client is able to provide partial self-care and will need pain medication. What setting is most appropriate for the client?
Keep the client's belongings secured in a locker.
A client has been admitted to the health care facility for less than 24 hours for observation. The client has a gold ring, watch, reading glasses, and other personal belongings. What care should the nurse take with regard to these objects?
"The needle causes pain when it goes in, but I will be by your side throughout and will help you hold your position."
A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is themost appropriate response by the nurse to this client?
"Tell me more about how you are feeling."
A female client reports to her primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that she does not want to take the test and feels she should instead continue with the medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?
evidence that nursing interventions have been evaluated in terms of the client's response.
A health care agency is applying for accreditation and the accrediting agency is conducting audits of randomly selected medical records. To support the agency's accreditation, these medical records should include
SOAP charting
A health care facility plans to evaluate and revise the plan of care for a client based on the client's medical 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?
to investigate the quality of care in the agency
A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?
Narrative charting
A nurse charting the medical record for a client knows that which form of charting involves writing information about the client and client care in chronological order?
"I know that you are anxious, but removal will be painless and the IV location needs to be changed."
A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?
include clearer descriptions of the client's mood and behavior.
A nurse has received change-of-shift report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." To improve the charting entry, it should
"You're worried about how you will tolerate the pain associated with labor."
A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?
"Is that a new shirt you're wearing?"
A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?
Encourage family discussions of feelings.
A nurse is caring for a terminally ill client whose death is imminent. The nurse has developed a close relationship with the family. Which intervention is most appropriate?
"I will close the door so you can spend some quiet time at the bedside."
A nurse is caring for an older adult client who has just died in a hospice unit. The child of the client arrives and asks, "Can I please stay and sit at the bedside? I really wanted to be here so they did not die alone." Which statement made by the nurse best demonstrates the use of empathy?
Use active listening during communication.
A nurse is caring for an older adult client. What strategy should the nurse include in order to facilitate effective communication?
Ensure that the client's medical record and nursing interventions are written.
A nurse is documenting the plan of care for a client with AIDS. Which of the following is most important when documenting the plan of care?
"Would you like to see my flashlight?"
A nurse is examining a 3-year-old child with conjunctivitis. During the examination, the child starts crying and refuses to sit still. Which statement is appropriate for the nurse to tell the child?
"Tell me more about how it feels to eat with your family."
A nurse pays a house visit to a client who is on parenteral nutrition (PN). The client expresses that he misses enjoying food with his family. What is the most appropriate response by the nurse?
Stop the LPN/LVN immediately and discuss the possible consequences of this action.
A nurse working with an experienced licensed practical/vocational nurse (LPN/LVN) delegates the task of administering oral medications to a team of clients. The nurse observes the LPN/LVN document a client's medication administration before entering the client's room. What is the most appropriate action of the nurse?
The client wishes to maintain and assert their personal identity.
An elderly client fell 2 days ago on the sidewalk near home and has been admitted to the hospital with a hip fracture. Since the subsequent surgery, the client he has been insistent on wearing their own sweater and cap. The nurse is aware that the client is not cold, has no cognitive deficits, and has participated cooperatively in all aspects of his treatment. What is the most plausible rationale for the client's action?
All risks disclosed Consent properly documented Capacity to refuse
The client has been assessed by the emergency department physician and nurse. The physician wants the client to be observed overnight. The client refuses and wants to leave. What are the components of a properly executed against medical advice (AMA) discharge based on this scenario? (Select all that apply.) A. Security notified B. All risks disclosed C. Consent properly documented D. Capacity to refuse E. Medication reconciliation
intermediate
The client is a disabled veteran with bilateral above the knee amputations (AKA). The client frequently has tender, erythemic areas along bilateral incision lines. Which type of facility will provide appropriate care for this client?
charting by exception
The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mm Hg when all other vital signs are normal. This reflects what type of documentation?
1600: Consumed 80%of breakfast. Reports pain level of 3 on scale of 1-10.
The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?
Verify current medications with the client's physician.
The nurse is transferring a stroke client to a long-term care facility. The client lived at home prior to the illness, but now is aphasic and unable to provide independent care. Which action made by the nurse demonstrates appropriate completion of the client's medication reconciliation?
Place one line through the entry, and initial.
The nurse makes an erroneous entry into the written health record. What is the appropriate nursing action?
Ensure that the client's name appears on all pages.
When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?
"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood sugar is 250, and I wondered if you would like to adjust the sliding scale insulin."
Which nurse to provider interaction correctly utilizes the SBAR format for improved communication?