NURS (FUNDAMENTAL): Ch 16 NCLEX Documanting

What ensures continuity of care? a) Integration b) Communication c) Critical thinking d) Reassessment

b) Communication Communication ensures continuity of care and provides essential data for revision or continuation of care.

When taking a telephone order from a physician, the nurse verifies that she understands the order by: a) confirming the order with the nurse manager. b) asking the physician to summarize the orders given. c) repeating the order back to the physician. d) faxing the written order to the physician's office.

c) repeating the order back to the physician.

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

d) The lower extremities Peripheral vascular disease (PVD) mostly affects the lower extremities.

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

c) Mark the date and time of the order. d) Read back the order. e) Include V.O. with the physician name on the order.

Which statement regarding FOCUS charting is most accurate? a) Problem, Intervention, Evaluation (PIE) charting is used with focused charting. b) Each note should include each section of the Data, Action, Response (DAR) format of charting. c) The charting focuses on client strengths, problems, or needs. d) The charting focuses on the injury or illness only.

c) The charting focuses on client strengths, problems, or needs. FOCUS charting focuses on client strengths, problems, or needs.

A nurse helps a patient who has cystic fibrosis prepare a standalone personal health record. Which statement by the nurse best explains this type of information? a) "You can link your record to a specific health care organization's electronic health record system." b) "Your entire health care team may access and securely share your vital medical information electronically." c) "Your health care provider is obligated to read your personal health record and share it with your insurance provider." d) "You can fill in information from your own records and store it on your computer or the Internet."

d) "You can fill in information from your own records and store it on your computer or the Internet." With a standalone personal health record, clients fill in information from their own records, and the information is stored on clients' computers or the Internet.

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? a) Leave spaces between entries and signature. b) Use abbreviations wherever possible. c) Record all facts and subjective interpretations. d) Ensure that the client's name appears on all pages.

d) Ensure that the client's name appears on all pages. The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting.

Which organization audits charts regularly? a) Sigma Theta Tau International b) American Nurses Association c) The Joint Commission d) National League for Nursing

c) The Joint Commission

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

d) Subjective data should be included when documenting.

A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate? a) "It will allow for us to see the client and possibly increase client participation in care." b) "It will give me a better sense of what my workload will be today." c) "It will let me see everything that has been done and things that need to be done." d) "It makes our client feel like we care, especially if we start the day off with a clean room."

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

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) 1U of glucose c) One U of glucose d) 1 bottle of glucose

a) 1 Unit of glucose

A nurse is using the SOAP format of documentation to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? a) A patient problem list b) Notes describing the patient's condition c) Overall trends in patient status d) Planned interventions and patient outcomes

a) A patient problem list When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Abnormal status can be seen immediately when using charting by exception, and planned interventions and patient expected outcomes are the focus of the case management model.

A nurse is taking care of a 15-year-old man with cystic fibrosis. The nurse is at the start of her shift and she goes in to the client's room to introduce herself 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 he is supposed to be on, she notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? a) Attach a copy of the incident report to the chart. b) Stop the infusion and document the time. c) Report error to primary provider. d) Fill out an incident report.

a) 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, fill out an incident report, stop the infusion and document the time, and report the error to the primary provider.

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? a) Charting by exception b) Problem, intervention, and evaluation note c) Narrative notes d) FOCUS data, action, and response note

a) Charting by exception The team would most likely suggest the use of charting by exception, which is an abbreviated form of documentation.

What ensures continuity of care? a) Communication b) Critical thinking c) Reassessment d) Integration

a) Communication

Which statement is not true regarding a medication administration record (MAR)? a) If the client refuses the dose you don't have to document this on the MAR. b) The MAR identifies routine times for medication administration. c) When using an electronic MAR, the nurse has to log off so that the next person using the computer does not sign off a medication under her name by mistake. d) The MAR distinguishes between routine and "as needed" medications

a) If the client refuses the dose you don't have to document this on the MAR.

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

a) Intake and output graphic sheet

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan? a) Progress notes b) Plan of care c) Data base d) Problem list

a) Progress notes

When documenting information in a client's medical record, what should the nurse do consistently for each entry? a) Sign each entry by name and title. b) Obtain a signature from the physician. c) Report each observation to the physician. d) Provide the day of the week on the entry.

a) Sign each entry by name and title.

How can the nurse researcher obtain information from a client record? a) Study client records. b) Audit discharge records. c) Interview nursing staff. d) Examine institutional procedures.

a) Study client records. Nursing and health care research is often carried out by studying client records.

Which are principles of documentation? Select all that apply. a) Timely b) Objective c) Confidentiality d) Accuracy e) Subjective

a, b, c, d The principles of proper documentation include confidentiality, accuracy, completeness, concise, objective, organized, timely, and legibility.

What information should the nurse document in the medication record when administering a non-narcotic pain medication? Select all that apply. a) Reason given b) Effectiveness of medication c) Dose d) Vital signs e) Time

a, b, c, e The nurse should document the medication given, time, route, dose, reason given, and effectiveness of the medication on the medication administration record.

A nurse is documenting the care given to a 56-year-old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? a) Erase or use correcting fluid to completely delete the error. b) Draw a single line through the entry and rewrite it above or beside it. c) Use a permanent marker to block out the mistaken entry and rewrite it. d) Remove the page with the error and rewrite the data on that page correctly.

b) Draw a single line through the entry and rewrite it above or beside it.

A friend of a nurse calls and asks if she is still working at Memorial Hospital. The nurse replies, "Yes." The friend tells the nurse that his girlfriend's father was just admitted as a patient and he wants the nurse to find out how he is. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? a) "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." b) "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." c) "Because of the Health Insurance Portability and Accountability Act, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" d) "Why do you think Sue isn't talking about her worries?"

b) "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks."

You are a nurse taking care of a 49-year-old man who was admitted for acute pancreatitis. He was admitted yesterday and has been on IV fluids, has been kept NPO (nothing by mouth), and has been given IV pain medications since. During your nursing assessment he tells you that his pain is a 4/10 on the pain scale. It starts out in his epigastric area and radiates to his back. He also has been nauseous this morning. Your facility charts by exception. You finish filling out the flow sheet and have to write a progress note. Which of the following is an example of writing a progress note that represents charting by exception for this patient? a) 4/10 pain located in epigastric area and radiating to back with nausea; on IV fluids b) 4/10 pain on pain scale, epigastric radiating to back; also complains of nausea c) NPO, 4/10 pain, epigastric radiating to back, nausea d) Forty-nine-year-old man, 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 2 mg IV dilaudid every 4 hours

b) 4/10 pain on pain scale, epigastric radiating to back; also complains of nausea Charting by exception charts only that which falls outside the standard of care and norms.

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines? a) Confused, belligerent, and uncooperative with care b) Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth c) Yelling at staff members, dementia worse today, refused breakfast d) Inappropriate behavior during breakfast, screamed during the shower, smiled while kicking other clients

b) Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Nursing documentation should focus on behaviors and avoid words such as better, normal, or worse. Using the terms inappropriate behavior or belligerent are judgmental statements. The actual behaviors witnessed should be documented.

What is the primary purpose of the client record? a) Advocacy b) Communication c) Research d) Education

b) Communication The primary purpose of the client record is to help health care professionals from different disciplines communicate with one another.

Which of the following is not a purpose of the medical record? a) Reimbursement b) Contract c) Legal document d) Care planning

b) Contract Medical records are legal documents, communication tools, and assessment tools. They are used for care planning purposes, quality assurance purposes, for reimbursement, research, and education.

According to the Health Insurance Portability and Accountability Act of 1996, if a health institution wants to release a patient's health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed? Select all that apply. a) News media are preparing a report on the condition of a public figure. b) Data are needed for the tracking and notification of disease outbreaks. c) Protected health information is needed by a coroner. d) Child abuse and neglect are suspected. e) Protected health information is needed to facilitate organ donation. f) The sister of a patient with Alzheimer's wants to help provide care.

b) Data are needed for the tracking and notification of disease outbreaks. c) Protected health information is needed by a coroner. d) Child abuse and neglect are suspected. e) Protected health information is needed to facilitate organ donation. Authorization is not required for tracking disease outbreaks, providing PHI to a coroner, reporting incidents of child abuse, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease.

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

b) 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, not covered with correcting fluid or erased.

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? a) FOCUS data, action, and response note b) Problem, intervention, and evaluation note c) Charting by exception d) Narrative notes

b) Problem, intervention, and evaluation note

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

b) Reporting

A client has requested a translator so that she can understand the questions that the nurse is asking her during the client interview. The nurse knows what is important when working with a client translator? a) That talking loudly helps the translator and the client understand the information better b) That translators may need additional explanations of medical terms c) That it is always okay to not use a translator if a family member can do it d) That talking directly to the translator facilitates the transfer of information

b) That translators may need additional explanations of medical terms It is true that even professional translators don't understand all medical terms and may need some clarification at times

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

b) Write a narrative note in the designated nursing section. Source oriented records have separate sections for each disciple 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 whose rehabilitation potential is not good b) a client who is homebound and needs skilled nursing care c) a client who is not making progress in expected outcomes of care d) a client whose status is stabilized

b) a client who is homebound and needs skilled nursing care

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? a) to transmit health records between insurance companies b) to investigate the quality of care in the agency c) to release the entire health record for research d) to inform family and others concerned about the client's care

b) to investigate the quality of care in the agency Medical records may occasionally be used to investigate the quality of care in the agency.

A nurse is taking care of a 66-year-old man post knee surgery. She is following a clinical pathway that guides the care of this client after this specific procedure. He is 2 days postoperative and the clinical pathway states that the nurse should advance his diet. The nurse enters the client's room to discuss this order and finds him vomiting in his wastebasket. A change in client care that deviates from the clinical pathway is called: a) deviation. b) variance. c) audit. d) never events.

b) variance. A variance occurs when the client does not proceed along a clinical pathway as planned.

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

c) "A coronary artery bypass graft will benefit your heart." Coronary artery bypass graft is abbreviated CABG.

A nursing instructor is discussing a nursing student's Facebook post about a very interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate? a) "You may continue to post about client you cared for during clinicals, as long as you do not use the client's name." b) "The information being posted on Facebook is inappropriate. Make sure to discuss information about client's privately with friends and family." c) "Any information that can identify a person is considered a breach of client privacy." d) "All aspects of the clinical experience are confidential and should not be discussed."

c) "Any information that can identify a person is considered a breach of client privacy."

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is: a) "Thank you for taking care of this!" b) Get a second nurse to listen to the order, and after writing the order on the physician order sheet, have both nurses sign it. c) "I am sorry, but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." d) Try calling another resident for the order or wait until the next shift.

c) "I am sorry, but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly."

A student nurse asks why completing an acuity report is important. What is the best response by the nurse? a) "It determines if a client needs to be transferred to a different unit." b) "It's the beginning step in determining the plan of care for the client." c) "It helps determine our staffing requirements." d) "It provides the pharmacy with the newest physician orders."

c) "It helps determine our staffing requirements." The use of an acuity report includes determining the number of staff needed to care for the clients on the unit. The acuity report does not determine the plan of care, or if a client needs to be transferred. Pharmacy is not impacted by the acuity report.

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appendicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines? Select all that apply. a) 6/12/15 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN b) 6/12/15 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN c) 6/12/15 0945 30 minutes following administration of morphine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d) 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e) 6/12/15 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN f) 6/12/15 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration.

c) 6/12/15 0945 30 minutes following administration of morphine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d) 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN f) 6/12/15 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "seems comfortable today." The nurse should never document an intervention before carrying it out.

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

c) 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.

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

c) 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 have or are at risk for developing.

A nurse takes a patient's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results? a) Progress notes b) Medical records c) Graphic sheets d) Flow sheets

c) Graphic sheets The graphic record is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.

A nurse is using the SBAR technique for hand-off communication when transferring a client. What are examples of the use of this process? Select all that apply. a) S: The nurse discusses the client's symptoms with the new nurse in charge. b) R: The nurse explains the rules of the new facility to the client. c) R: The nurse gives recommendations for future care to the new nurse in charge. d) S: The nurse handling the transfer describes the client situation to the new nurse. e) B: The nurse gives the background of the client by explaining the client history. f) A: The nurse presents an assessment of the client to the new nurse.

c) R: The nurse gives recommendations for future care to the new nurse in charge. d) S: The nurse handling the transfer describes the client situation to the new nurse. e) B: The nurse gives the background of the client by explaining the client history. f) A: The nurse presents an assessment of the client to the new nurse.

The nursing is caring for a client who requests to see a copy of his or her medical records. What action by the nurse is most appropriate? a) Access the medical record at the bedside and show the client how to navigate the electronic medical record. b) Explain that only a paper copy of the medical record can be viewed by the client. c) Review the hospital's process for allowing clients to view their medical records. d) Discuss how the hospital can be fined for allowing clients to view their medical records.

c) Review the hospital's process for allowing clients to view their medical records. The nurse needs to be aware of the policies regarding clients reviewing medical records.

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

c) 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.

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

c) interpretation of data. It is always best to describe behavior rather than to interpret behavior. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client. Stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement.

A nurse is transfusing multiple units of packed red blood cells (PRBCs). 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) "It seems like this client has fluid volume overload." c) "This client has a medical history of heart failure." 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 provides a consistent method for hand-off communication that is clear, structured, and easy to use.

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? a) "I'm sorry, but patients are not allowed to copy their medical records." b) "I can make a copy of your record for you right now." c) "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." d) "I will need to check with our records department to get you a copy."

d) "I will need to check with our records department to get you a copy."

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) "CBE is the best way to protect against lawsuits." b) "CBE is a relatively new format of documentation in electronic health records." c) "The benefit of CBE is it demonstrates whether high quality care is given." d) "The benefit of CBE is less time needed on computer charting."

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

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? a) Every three hours b) Every four hours c) Daily d) As needed

d) As needed

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? a) Accessing the electronic medical record of the family member to find out extent of injury b) Asking the emergency department nurse for information on the family member c) Finding the emergency medical technicians that transported the family members about the injuries d) Calling the client information desk to find out the room number of the family member

d) Calling the client information desk to find out the room number of the family member

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? a) Variance charting b) FOCUS charting c) Problem, Intervention, Evaluation (PIE) charting d) Charting by exception (CBE)

d) Charting by exception (CBE) Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes.

A nurse administering medications accidentally gives a double dose of blood pressure medications. After ensuring the safety of the client, the nurse would document the error in which documents? a) Occurrence report and critical pathway b) Critical pathway and care plan c) Care plan and client's record d) Client's record and occurrence report

d) 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.

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? a) Admission sheet b) Admission nursing assessment c) Activity flow sheet d) Graphic record

d) Graphic record While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the activity flow sheet.

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

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

A nurse documents the following patient data in the patient record according to the SOAP format: Patient complains of unrelieved pain; patient is seen clutching his side and grimacing; patient 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) PIE charting method b) Source-oriented method c) Focus charting method d) Problem-oriented method

d) 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 patient problems and contributes collaboratively to the plan of care.

A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication? a) States pain is not relieved, talking with family on phone. b) Rates pain 8/10, states nauseated for last 30 minutes. c) Rates pain higher on pain scale, notified physician. d) Vital signs within normal limits, sleeping.

d) Vital signs within normal limits, sleeping.

Which documentation by the nurse best supports the PIE charting system? a) Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea 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) Vomiting 250 mL undigested food, antiemetic given, no further vomiting

d) 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 using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the order in which they should be performed. a) "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b) "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c) "You want me to discontinue the PCA pump until you see him tonight at patient rounds." d) "I am Rosa Clark, an RN working on the second floor of South Street Hospital." e) "Mr. Sanchez was admitted two days ago following a diagnosis of pancreatic cancer." f) "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d, a, e, b, f, c. The order for ISBARR is: identity/introduction, situation, background, assessment, recommendation, and read-back.