Prepu Ch 19 Documenting & Reporting
Which abbreviation is correct for use in documentation? a. Sub q b. BT c. Per os d. PO
d. PO
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.
Which components should the nurse include when documenting a critical pathway? Select all that apply. a. Care plan b. Timeline c. Subjective data d. Significant deviations e. Expected outcomes
a. Care plan b. Timeline e. Expected outcomes
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. "Will you prescribe a complete blood count to check the white blood cell count and a culture?" b. "The client was admitted today with a urinary tract infection." c. "The client's temperature has been 102°F (38.9°C) for the last 6 hours." d. "I am concerned that the client might be exhibiting sepsis."
a. "Will you prescribe a complete blood count to check the white blood cell count and a culture?"
A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? a. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. b. Client states expecting some pain, but it is more severe than anticipated. c. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." d. Client is requesting pain medications, is grimacing, and is diaphoretic.
c. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."
The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? a. Contact information technology (IT) staff to make the correction. b. Immediately delete the incorrect documentation. c. Create an addendum with a correction. d. Contact the health care provider.
c. Create an addendum with a correction.
A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? a. Review the laboratory results under the physician section. c. Write a narrative note in the designated nursing section. d. Use a critical pathway to document the physical assessment. e. Place the narrative note chronologically after the respiratory therapist's note.
c. Write a narrative note in the designated nursing section.
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 is coughing and experiencing severe heartburn in the morning. b. The client has symptoms in the morning associated with a heart attack. c. The client reports waking up this morning with a severe headache. d. The client has a history of severe complaints in the morning.
c. The client reports waking up this morning with a severe headache.
Which is the primary purpose of client records? a. Communication b. Reimbursement c. Legal protection d. Performance improvement
a. Communication
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. Telemedicine report c. Transfer report d. Nurse's shift report
a. Incident report
The nurse hears an unlicensed assistive personnel (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. Document the UAP's conversation. c. Report the UAP to the nurse manager. d. Notify the client relations department about the breach of privacy.
a. Remind the UAP about the client's right to privacy.
A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? a. 1U of glucose b. 1 Unit of glucose c. One U of glucose d. 1 bottle of glucose
b. 1 Unit of glucose
What ensures continuity of care? a. integration b. reassessment c. communication d. critical thinking
c. communication
Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? a. "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin." b. "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." c. "I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." d. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."
d. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."
Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? a. Omitting clients' responses to nursing interventions b. Documenting clients' health histories and discharge planning c. Identifying nursing diagnoses or clients' needs d. Recording nursing interventions
a. Omitting clients' responses to nursing interventions
A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply. a. S: The nurse handling the transfer describes the client situation to the new nurse. b. S: The nurse discusses the client's symptoms with the new nurse in charge. c. R: The nurse explains the rules of the new facility to the client. d. B: The nurse gives the background of the client by explaining the client history. e. R: The nurse gives recommendations for future care to the new nurse in charge. f. A: The nurse presents an assessment of the client to the new nurse.
a. S: The nurse handling the transfer describes the client situation to the new nurse. d. 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. e. R: The nurse gives recommendations for future care to the new nurse in charge.
A client is scheduled for a CABG procedure. What information should the nurse provide to the client? a. "The CABG procedure will help identify nutritional needs." b. "A coronary artery bypass graft will benefit your heart." c. "The CABG procedure will help increase intestinal motility and prevent constipation." d. "A complete ablation of the biliary growth will decrease liver inflammation."
b. "A coronary artery bypass graft will benefit your heart."
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. An audit b. A variance c. A sentinel event d. A never event
b. A variance
Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. a. Making the names of clients on charts visible to the public b. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public c. Obscuring identifiable names of clients and private information about clients on clipboards d. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards e. Keeping record of people who have access to clients' records
b. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public c. Obscuring identifiable names of clients and private information about clients on clipboards e. Keeping record of people who have access to clients' records
The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? a. Discuss how the hospital can be fined for allowing clients to view their health care records. b. Review the hospital's process for allowing clients to view their health care records. c. Access the health care record at the bedside and show the client how to navigate the electronic health record. d. Explain that only a paper copy of the health care record can be viewed by the client.
b. Review the hospital's process for allowing clients to view their health care records.
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. "Are you questioning the care of your child?" b. "No, the physician will not give you access to review the records." c. "I will arrange access for you to review the record after you put your request in writing." d. "Only the client has the right to review the health care records."
c. "I will arrange access for you to review the record after you put your request in writing."
Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing? a. Podiatry referral b. Pulmonologist referral c. Nutritional consult d. Social services consult
c. Nutritional consult
A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: a. a consultation. b. reporting. c. conferring. d. a referral.
d. a referral.
Which is the proper way to document midnight in a client's record? a. 2401 b. 1201 c. 0000 d. 1200
c. 0000
A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. 1. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. 2. "I don't feel well. I've been urinating often, and it burns when I urinate." 3. Fever, possible urinary tract infection 4. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago.
2. "I don't feel well. I've been urinating often, and it burns when I urinate." 4. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 3. Fever, possible urinary tract infection 1. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.
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. "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." c. "You may continue to post about a client, as long as you do not use the client's name." d. "All aspects of clinical practice are confidential and should not be discussed."
a. "Any information that can identify a person is considered a breach of client privacy."
A new graduate is working at a first job. Which statement is most important for the new nurse to follow? a. Document lengthy entries using complete sentences. b. Only document changes in the client's status. c. Use PIE charting, even if it is not the institution's charting method. d. Use abbreviations approved by the facility.
d. Use abbreviations approved by the facility.
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.
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. Calling the client information desk to find out the room number of the family member b. Accessing the electronic health record of the family member to find out extent of injury c. Asking the emergency department nurse for information on the family member d. Finding the emergency medical technicians who transported the family members and inquiring about the injuries
a. Calling the client information desk to find out the room number of the family member
Which are appropriate actions for protecting clients' identities? Select all that apply. a. Document all personnel who have accessed a client's record. b. Place light boxes for examining X-rays with the client's name in private areas. c. Have conversations about clients in private places where they cannot be overheard. d. Orient computer screens toward the public view. e. Ensure that clients' names on charts are visible to the public.
a. Document all personnel who have accessed a client's record. b. Place light boxes for examining X-rays with the client's name in private areas. c. Have conversations about clients in private places where they cannot be overheard.
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 emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. b. -oriented recording gives clients the right to withhold the release of their information to anyone. c. 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. d. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers.
a. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.
The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? a. The client reports that on a scale of 0 to 10, the current pain is a 3. b. The client appears to have a low tolerance for pain and frequently reports intense pain. c. The client is receiving sufficient relief from pain medication, stating no pain in either knee. d. The client appears comfortable and is resting adequately and appears to not be in acute distress.
a. The client reports that on a scale of 0 to 10, the current pain is a 3.
Which example may illustrate a breach of confidentiality and security of client information? a. The nurse provides information over the phone to the client's family member who lives in a neighboring state. b. The nurse provides information to a professional caregiver involved in the care of the client. c. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell. d. The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria
a. The nurse provides information over the phone to the client's family member who lives in a neighboring state.
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 makes our client feel like we care, especially if we start the day off with a clean room." b. "It will allow for us to see the client and possibly increase client participation in care." c. "It will let me see everything that has been done and things that need to be done." d. "It will give me a better sense of what my workload will be today."
b. "It will allow for us to see the client and possibly increase client participation in care."
Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edematous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? a. Exception b. FOCUS c. PIE d. Narrative
b. FOCUS Explanation 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
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. Call the pharmacy to have the order entered in the electronic record. b. Inform the health care provider that a written order is needed. c. Write the order in the client's record. d. Add the new order to the medication administration record.
b. Inform the health care provider that a written order is needed.
The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? a. Objective data are what the client states about the problem. b. Subjective data should be included when documenting. c. The plan includes interventions, evaluation, and response. d. Abnormal laboratory values are common items that are documented.
b. Subjective data should be included when documenting.
The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? a. The provider can input orders remotely into the EHR system for the nurse to retrieve. b. The nurse can accept verbal orders to provide immediate care and record once the client is stable. c. The client must be stabilized before the nurse can obtain any orders from the provider. d. The nurse can implement care once written orders are received from the provider.
b. The nurse can accept verbal orders to provide immediate care and record once the client is stable.
Which finding from a nursing audit reflects high standards for client safety and institutional health care? a. The nurse fails to identify the nursing diagnoses or clients' needs. b. The nurse documents clients' responses to nursing interventions. c. The nurse fails to adequately complete data on clients' health histories and discharge planning. d. The nurse records inappropriate nursing interventions.
b. The nurse documents clients' responses to nursing interventions.
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 meets with nurses or other health care professionals to discuss some aspect of client care. c. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. d. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing
b. The nurse meets with nurses or other health care professionals to discuss some aspect of client care.
A client's record can be more accurate if the nurse: a. summarizes client care at the end of the shift. b. uses point-of-care documentation. c. charts at least every 6 hours. d. delegates charting appropriately.
b. uses point-of-care documentation.
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. Provide the information to the parent. b. Explain the reasons for the hospitalization, but give no further information. c. Ask the client if information can be given to the parent. d. Take the parent to the client's room and have the client give the requested information.
c. Ask the client if information can be given to the parent.
Which note includes all elements of a SOAP note? a. 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. b. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. c. 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. d. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess.
c. 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 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. PIE charting method b. Focus charting method c. Problem-oriented method d. Source-oriented method
c. Problem-oriented method Explanation: *The problem-oriented method is organized around a client's problems rather than around sources of information. **Source-oriented method is a paper format in which each health care group keeps data on its own separate form ***PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. ****Focus charting method brings the focus of care back to the client and the client's concerns.
The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse? Select all that apply. a. Have the health care provider review and sign the prescription during the emergency. b. Record the prescription on the pharmacy discrepancy sheet. c. Read back the prescription. d. Record the date and time of the prescription. e. Include V.O. with the health care provider's name on the prescription.
c. Read back the prescription. d. Record the date and time of the prescription. e. Include V.O. with the health care provider's name on the prescription
Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? a. A client who resides in Indiana has required hospitalization during a vacation in Hawaii. b. A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. c. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. d. A client has asked a nurse if he can read the documentation that his physician wrote in his chart.
d. A client has asked a nurse if he can read the documentation that his physician wrote in his chart.
