(Fund Ch 19) PrepU

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? a. "A coronary artery bypass graft will benefit your heart." b. "The CABG procedure will help identify nutritional needs." c. "A complete ablation of the biliary growth will decrease liver inflammation." d. "The CABG procedure will help increase intestinal motility and prevent constipation."

a. "A coronary artery bypass graft will benefit your heart." Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? a. "Any information that can identify a person is considered a breach of client privacy." b. "You may continue to post about a client, as long as you do not use the client's name." c. "All aspects of clinical practice are confidential and should not be discussed." d. "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."

a. "Any information that can identify a person is considered a breach of client privacy." Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.

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? a. "I will arrange access for you to review the record after you put your request in writing." b. "No, the physician will not give you access to review the records." c. "Are you questioning the care of your child?" d. "Only the client has the right to review the health care records."

a. "I will arrange access for you to review the record after you put your request in writing." Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the physician not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.

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? a. Incident report b. Nurse's shift report c. Transfer report d. Telemedicine report

a. Incident report An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? a. Inform the health care provider that a written order is needed. b. Write the order in the client's record. c. Call the pharmacy to have the order entered in the electronic record. d. Add the new order to the medication administration record.

a. Inform the health care provider that a written order is needed. Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

Which abbreviation is correct for use in documentation? a. PO b. Sub q c. Per os d. BT

a. PO Facilities develop acceptable abbreviation lists based on guidelines from oversight agencies. PO, which is a derivatiive abbreviation from the Latin term "per os," signifying "orally" or "by mouth," is a commonly approved abbreviation. "Sub q" (meaning "subcutaneous"; SC is preferred), "Per os" (meaning "orally" or "by mouth"; PO is preferred), and "BT" (meaning "bedtime"; can be confused with "BID," meaning "twice daily") are not generally accepted abbreviations.

The nurse receives a verbal order from a physician during an emergency situation. Which actions should be taken by the nurse? Select all that apply. a. Read back the order. b. Mark the date and time of the order. c. Include V.O. with the physician name on the order. d. Have the physician review and sign the order during the emergency. e. Record the order on the pharmacy discrepancy sheet.

a. Read back the order. b. Mark the date and time of the order. c. Include V.O. with the physician name on the order. When a verbal order is received during an emergency, the nurse should record the order in the medical record, read back the order, mark the date and time of the order, and record V.O. with the name of the physician who issued the order. After the emergency situation, the physician should review and sign the order. Pharmacy discrepancy sheets are used to record discrepancies in medication inventories, which could indicate diversion, or theft, of prescription medications.

The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply. a. Readable b. Thoughtful c. Timely d. Clear, concise, and complete e. Accurate, relevant, and lengthy f. Retrievable on a temporary basis

a. Readable b. Thoughtful c. Timely d. Clear, concise, and complete Characteristics of effective documentation include accessible, accurate, relevant, consistent, auditable, clear, concise (not lengthy), complete, legible/readable, thoughtful, timely, contemporaneous, sequential, and retrievable on a permanent (not temporary) basis.

The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? a. Remind the UAP about the client's right to privacy. b. Report the UAP to the nurse manager. c. Notify the client relations department about the breach of privacy. d. Document the UAP's conversation.

a. Remind the UAP about the client's right to privacy. The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediately protect the client's privacy.

The nursing 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? a. Review the hospital's process for allowing clients to view their health care records. b. Access the health care record at the bedside and show the client how to navigate the electronic health record. c. Discuss how the hospital can be fined for allowing clients to view their health care records. d. Explain that only a paper copy of the health care record can be viewed by the client.

a. Review the hospital's process for allowing clients to view their health care records. The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the 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? 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 is coughing and experiencing severe heartburn in the morning. d. The client has a history of severe complaints in the morning.

a. The client reports waking up this morning with a severe headache. The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn.

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

a. The lower extremities Peripheral vascular disease mostly affects the lower extremities. While the lung sounds, heart rate and rhythm, and abdominal assessment will be important, the focused assessment should be on the lower extremities.

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation? a. The nurse could be fined or even go to jail for violating HIPAA. b. No action will be taken as long as the parents don't find out. c. There will be no repercussions if the nurse takes the photo down from the social media page. d. The nurse could be fired but would not face criminal charges or jail time.

a. The nurse could be fined or even go to jail for violating HIPAA. The nurse has committed a HIPAA violation and most likely breached the facility's social media policy. The nurse has placed a newborn and family at risk by posting photos to a social media website where anyone is at liberty to view the page. The nurse may well be dismissed for this infraction and is at risk for fines and imprisonment for a HIPAA violation, even if the nurse takes the photo down and the parents do not find out. The managers at the facility should enforce the social media policy, explain violations and consequences to all staff, and have them sign the social media policy.

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

a. Vomiting 250 mL undigested food, antiemetic given, no further vomiting PIE charting includes the problem, intervention, and evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (problem), antiemetic given (intervention), no further vomiting (evaluation).

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? a. Write a narrative note in the designated nursing section. b. Place the narrative note chronologically after the respiratory therapist's note. c. Review the laboratory results under the physician section. d. Use a critical pathway to document the physical assessment.

a. Write a narrative note in the designated nursing section. Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a. a client who is homebound and needs skilled nursing care b. a client whose rehabilitation potential is not good c. a client whose status is stabilized d. a client who is not making progress in expected outcomes of care

a. a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

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

a. a flow sheet A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.

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

a. education of student nurses b. reimbursement for services c. research e. education for medical students The client medical record may be used for education of a variety of health care professionals, reimbursement, and research. The record is never used to give information to callers without written authorization from the client.

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

a. have the right to copy their health records. HIPAA affords clients the right to see and copy their health records, update their health records, and get a list of disclosures that a health care institution has made for the purposes of treatment, payment, and health care operations. Clients have the right to request a restriction on certain uses or disclosures and choose how to receive this health information. HIPAA includes punishments for anyone caught violating client privacy, but these punishments are not directed at the client because HIPAA was implemented to protect the privacy of an individual's health information.

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? a. identifying risks and ensuring future safety for clients b. gauging the nurse's professional performance over time c. protecting the nurse and the hospital from litigation d. following up the incident with other members of the care team

a. identifying risks and ensuring future safety for clients Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.

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. a. name of the client b. intake and output prior to surgery c. client discharge teaching needs d. type of insurance e. personal feelings about the client f. current vital signs

a. name of the client b. intake and output prior to surgery c. client discharge teaching needs f. current vital signs The client's name should be included in the report, as well as age, room number, and physician. Intake and output prior to surgery is important to provide, as it establishes a baseline. Client discharge teaching may be included, as according to chapter 8 (Client Learning), discharge plans start with admission. Current vital signs indicate current status. Payor source and personal feelings are not relevant for the report.

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

a. subjective data should be included when documenting. Subjective data should be included when using the SOAP format for documentation. Objective data are what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care provider's judgment of the situation, and abnormal lab values would be included in objective data.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? a. subjectivity b. objectivity c. organization d. reimbursement

a. subjectivity Quoting what the client is saying helps in the documentation of subjective data. Objective data are assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.

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? a. those directly involved in the client's care b. any family member of the client c. close friends of the client d. health care professionals of the facility

a. those directly involved in the client's care Only those directly involved in client care are entitled to access the client's information. Family members and close friends do not have access to the client's records, as per the privacy policy applicable to each client. Health care professionals of the health care facility may not access client information unless involved in that client's care at that time.

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. A never event b. A variance c. An audit d. A sentinel event

b. A variance This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client.

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? a. Fill out an incident report. b. Attach a copy of the incident report to the chart. c. Stop the infusion and document the time. d. Report the error to the primary provider.

b. Attach a copy of the incident report to the chart. For legal reasons, the nurse should not attach a copy of the incident report to the chart. The nurse should, however stop the infusion and document the time, report the error to the primary provider and nursing supervisor, and fill out an incident report,

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? a. PIE b. FOCUS c. Narrative d. Exception

b. FOCUS The nurse used FOCUS charting, as it gives priority attention to the client's current or changed behavior. PIE charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating PIE, narrative, or exception charting.

Which flow sheet provides the health care provider with information on an ongoing record of fluid loss? a. Vital signs graphic sheet b. Intake and output graphic sheet c. Critical care flow sheet d. Health assessment flow sheet

b. Intake and output graphic sheet The intake and output graphic sheet is used to maintain an ongoing record of all fluid intake and output. The vital signs graphic sheet is used to record specific patient variables, such as pulse, respiratory rate, blood pressure readings, and body temperature. The critical care flow sheet is used to record nursing interventions used in critical care. The health assessment flow sheet is used to record health assessments that the nurse performs on a client.

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

b. SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

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? a. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. b. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. c. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. d. The nurse sends or directs someone to take action in a specific nursing care problem.

b. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

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

b. Use minimum disclosure policy to release the information. The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment.

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

b. interpretation of data. A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.

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. Kardex. d. incident report.

b. legal document. The client record serves as a legal document of the client's health status and care received. An assessment tool may be a formal document that is included as part of the client's record. A Kardex is typically an erasable, temporary document that would be shredded when no longer needed for the client's care. Incident reports are internal documents that are not a part of the client's record, and therefore not a legal document regarding their health care.

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

b. uses point-of-care documentation. Point-of-care documentation takes place as care occurs, thus enhancing accuracy. Today many facilities incorporate technology that is mobile and can be used immediately at the client's bedside for point-of-care documentation. The nurse should not delegate documentation, nor should it be left to the end of a shift. Documentation should be performed more than once every 6 hours.

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

c. "According to HIPAA legislation, you have a right to request changes to inaccurate information." The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.

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

c. Document all personnel who have accessed a client's record. d. Place light boxes for examining X-rays with the client's name in private areas. e. Have conversations about clients in private places where they cannot be overheard. Documenting all personnel who have accessed a client's record, placing light boxes for examining X-rays with the client's name in private areas, and having conversations about clients take place in privatewhere they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Orienting computer screens toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of patient confidentiality.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? a. Recording nursing interventions b. Identifying nursing diagnoses or clients' needs c. Omitting clients' responses to nursing interventions d. Documenting clients' health histories and discharge planning

c. Omitting clients' responses to nursing interventions Omitting clients' responses to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health histories and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.

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

c. Precise measurements should be used rather than approximations. Precise measurements and times must be used whenever possible. It is appropriate to use the names of physicians and photographs can constitute documentation. Handwritten entries should be struck through with a single line and initialed, not covered with correcting fluid or erased.

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? a. Source-oriented method b. PIE charting method c. Problem-oriented method d. Focus charting method

c. Problem-oriented method The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically. PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care.

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? a. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. b. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. c. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. d. 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.

c. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having 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 are examples of source-oriented recording.

In SBAR, what does R stand for? a. Reinforcing data b. Response c. Recommendations d. Report

c. Recommendations SBAR stands for situation, background, assessment, and recommendations. The other responses are incorrect.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? a. Dialogue b. Documentation c. Reporting d. Verification

c. Reporting Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? a. Disclosing client health information for research purposes after obtaining permission from the client's physician b. Releasing the client's entire health record when only portions of the information are needed c. Submitting a written notice to all clients identifying the uses and disclosures of their health information d. Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

c. Submitting a written notice to all clients identifying the uses and disclosures of their health information Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the physician's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

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

c. To serve as a contract with the client Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained.

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

c. urine output 100 ml Objective data, such as the measurable urine output, are collected by the nurse. Subjective data, such as feeling pain, itchiness, or fatigue, are reported by the client.

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

d. "I think the client would benefit from intravenous furosemide." Situation, background, assessment, and recommendations (SBAR) provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (situation) and B (background) provide objective data, whereas the A (assessment) and R (recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating that the client has fluid volume overload is the assessment of the nurse. Stating that the nurse thinks the client would benefit from intravenous furosemide is the nurse's recommendation.

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

d. "Will you prescribe a complete blood count to check the white blood cell count and a culture?" SBAR is an acronym for Situation, Background, Assessment, Recommendation. Situation is what the nurse describes, the current situation. Background is the pertinent information regarding the current situation. Assessment is objective information that supports the situation. Recommendation is what the nurse recommends to the health care provider. In this case, the Recommendation is the nurse asking the provider to prescribe a complete blood count and culture. "I am concerned that the client might be exhibiting sepsis" is a situation statement. "The client's temperature has been 102°F (38.9°C) for the last 6 hours" is the assessment of the client supporting the situation. The client being admitted today with a urinary tract infection is Background.

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use? a. 0815 b. 0945 c. 1945 d. 2015

d. 2015 Military time uses a 24-hour time cycle instead of two 12-hour cycles. So, 8:15 p.m. is equivalent to 2015.

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? a. Notifying the nursing team of the client's condition b. Documenting client data on the flow sheet c. Keeping an accurate medication record d. Accurately documenting client care on the client record

d. Accurately documenting client care on the client record The client record is the only permanent legal document that details the nurse's interactions with the client and is the nurse's best defense if a client or client surrogate alleges nursing negligence. As the question is written, the only answer that addresses the situation is accurate documentation of the event in the client's record. Notifying the nursing team of the client's condition is important, but not the correct answer for the question. Client data should be correctly documented on the flow sheet, but this is not the correct answer in this case. The medication record should be accurate, but this is not the best answer.

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

d. It provides quick access to abnormal findings. Charting by exception (CBE) provides quick access to abnormal findings, as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

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

d. Translators may need additional explanations of medical terms. When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.

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? a. SOAP b. narrative c. focus d. charting by exception

d. charting by exception Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.

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? a. data base b. problem list c. plan of care d. progress notes

d. progress notes In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

What dual purpose does an audit serve? a. communication and evaluation b. knowledge and quality c. education and confidentiality d. quality assurance and reimbursement

d. quality assurance and reimbursement Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits have no role in communications, evaluation, knowledge, quality, education, or confidentiality,

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. a. "I will write, print, or type information legibly." b. "I will use only agency-approved abbreviations." c. "I will draw a straight line through any blank space." d. "I will stay logged in on the computer until the end of my shift." e. "I will elaborate on the details on my entry in the clients' records."

a. "I will write, print, or type information legibly." b. "I will use only agency-approved abbreviations." c. "I will draw a straight line through any blank space." Writing, printing, or typing information legibly will prevent the entry from losing its value for exchanging information if it is unreadable. Using only agency-approved abbreviations promotes consistency in interpretation. Drawing a straight line through any blank space will reduce the possibilities that someone else will add information to the current documentation. Staying logged in on the computer until the end of the shift is incorrect, as it is a security risk. Best practice is that the nurse logs off each time the nurse has completed an entry. Elaborating on the details on the entry in the clients' records is not in keeping with best practice. The entry should be brief but complete.

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? a. "It will allow for us to see the client and possibly increase client participation in care." b. "It will let me see everything that has been done and things that need to be done." c. "It makes our client feel like we care, especially if we start the day off with a clean room." d. "It will give me a better sense of what my workload will be today."

a. "It will allow for us to see the client and possibly increase client participation in care." Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

The health care provider tells the client, "You are experiencing an MI," and leaves the room. The client asks the nurse what an MI stands for. What response by the nurse is most accurate? a. "Myocardial infarction." b. "Muscle infection." c. Myopia instability." d. "Mitochondria inflammation."

a. "Myocardial infarction." The common abbreviation for myocardial infarction is MI.

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

a. "The benefit of CBE is less time needed on computer charting." One of the benefits of CBE is less time needed for documentation. CBE does not always support high-quality care and is not the best way to protect against lawsuits since not all data are documented. CBE is not a new format for documentation.

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. 1 Unit of glucose The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit" instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."

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

a. 2130 Military time uses the 24-hour clock cycle. So, 9:30 p.m. is 2130 in military time.

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

a. Ask the client if information can be given to the parent. No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy.

The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate? a. Assess the triggers from the data. b. Document the findings on an occurrence report. c. Provide a comprehensive written report to the client ombudsperson. d. Repeat the minimum data set in 2 weeks.

a. Assess the triggers from the data. Once the minimum data set is complete, it will identify elements or triggers for issues that the resident either has or is at risk for developing. The information should not be documented on an occurrence report, as it is not is a comprehensive written report required to be sent. There is no need to complete the minimum data set in 2 weeks unless the resident has a significant change in condition.

Which note includes all elements of a SOAP note? a. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. b. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. c. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. d. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess.

a. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. A SOAP note consists of subjective information, objective information, an assessment, and a plan. The correct response includes each of these while the remaining three responses are each lacking a different one of the components.

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? a. Client's record and occurrence report b. Occurrence report and critical pathway c. Critical pathway and care plan d. Care plan and client's record

a. Client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? a. Documentation b. Accreditation c. Psychomotor skills d. Clinical judgment

a. Documentation Documentation is the primary source of evidence used to measure performance outcomes, according to the CNA. Accreditation is the process whereby educational institutions are evaluated and, if approved, certified by a third party to validate their compentency. Psychomotor skills are skills that require physical actions and mucular coordination to perform. Clinical judgment is an attribute of health care professionals that involves the use of critical thinking, intuition, and clinical experience when making a decision about a client's care to achieve the best outcome for the client.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate? a. Explain the reason why information cannot be disclosed. b. Verify the insurance coverage before giving information. c. Refer the parent to the physician providing care. d. Mediate a meeting between the parent and client.

a. Explain the reason why information cannot be disclosed. The nurse needs to explain the reason why information cannot be released to the parents. Providing insurance coverage does not negate the privacy laws. Referring the parent to the physician is inappropriate since the physician cannot release the information either. Mediating a meeting between the parent and client would only be appropriate if the client requested the meeting.

Which statement is not true regarding a medication administration record (MAR)? a. If the client declines the dose, the nurse does not have to document this on the MAR. b. The MAR distinguishes between routine and "as needed" medications. c. The MAR identifies routine times for medication administration. d. After using an electronic MAR, the nurse should log off.

a. If the client declines the dose, the nurse does not have to document this on the MAR. If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it. MARs can distinguish between routine and "as needed" medications identify routine times for medication administration. After using an electronic MAR, the nurse should log off to prevent others from inadvertenly adding information about other clients to the initial client's record.