PrepU Chapter 4
A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which statement?
"I think this client would benefit from an antiemetic."
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?
An assessment flow chart
Abnormal assessment findings are clearly outlined in which documentation format? Narrative charting Focus note PIE charting Charting by exception
Charting by exception
A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.
Determining eligibility for reimbursement Legal document of care A method to gather research data Promoting effective communication between caregivers
A nurse is explaining to other nurses on the unit about diagnosis-related groups (DRGs). On what documentation do insurance companies base their payment approval/disapproval?
Diagnosis codes
When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?
It becomes the foundation for the entire nursing process.
The nurse responds to a call light for a client rating their pain "ten out of ten." The nurse's initial inspection reveals the client is watching videos and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain? Ask the client to repeat his rating of his pain in five minutes. Consult the client's medication administration record to check for recent analgesic use. Perform further assessments addressing various aspects of the client's pain. Observe the client for several seconds to see if his demeanor or his behavior changes.
Perform further assessments addressing various aspects of the client's pain.
The nurse is caring for a client with influenza symptoms and is documenting the initial and ongoing assessment database. What would the nurse emphasize as the major rationale for this action? Maximizing the efficiency of care Facilitating achievement of professional standards Promoting communication between disciplines Reducing the fragmentation of care
Promoting communication between disciplines
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication? DAR SOAP SBAR PIE
SBAR
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication? SBAR SOAP DAR PIE
SBAR
A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following? Data and results Observation and inspection Interpretation and inference Evaluate nursing care provided Subjective data and objective data
Subjective data and objective data
A nurse is recording some vital signs in a 12-year-old girl's chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client as reasons for documenting assessment findings? Select all that apply. To determine the educational needs of the client To prevent delays in carrying out the plan of care To ensure that only the nurse is aware of the assessments To eliminate the possibility of diagnosing new problems
To prevent delays in carrying out the plan of care To determine the educational needs of the client
The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use? Written handoff Focus note Verbal handoff Patient Assessment Instrument
Verbal handoff
A nurse is interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process? Implementation Evaluation Planning Analysis
analysis
Nurses are aware that "handoff" can significantly increase the risk for errors. Common examples of "handoffs" are as follows (check all that apply): when a patient is transferred from the PACU to the floor upon admission to the ED when a nurse leaves for lunch when a patient is discharged at change of shift
at change of shift when a nurse leaves for lunch when a patient is transferred from the PACU to the floor
A nurse is caring for a patient who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:
charting by exception
A client is having frequent blood pressure and blood glucose measurements to regulate an insulin infusion. Which type of documentation should the nurse use for this data? Flow sheet Checklist Narrative note Specialty assessment form
flow sheet
A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data? Focused assessment form Ongoing assessment form Open-ended form Frequent assessment form
focused assessment form
The nurse documents data immediately after assessing the patient. This is an example of:
point of care documentation
The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection
A 54-year-old client is receiving a follow-up assessment in a clinic, following abnormal findings on her recent mammogram. Which of the following statements best reflects appropriate documentation by the nurse?
"Client has unkempt appearance and avoids eye contact"
What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the home care setting? APIE OASIS SOAPIE CAME
OASIS
A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply): complete concise accurate biased timely organized
accurate organized complete timely concise
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? Progress notes Plan of care Problem list Data base
progress notes
The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?
progress notes
The nurse prepares information to provide to the nurse scheduled to work the next shift. Which type of communication is the nurse preparing?
hand-off report
How does the client's medical record affect financial reimbursement? (select all that apply.) Insurance companies audit client records to ensure that billing is accurate Documentation does not support specific interventions that a care provider ordered Financial reimbursement is authorized without detailed charting of assessments and interventions Financial reimbursement is not affected by documentation
Insurance companies audit client records to ensure that billing is accurate
While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding? "Reddened area noted on skin surface superficial to client's coccyx." "Impaired skin integrity related to decreased mobility." "Area of nonblanching erythema noted over client's coccyx, 2 cm × 2 cm." "Possible pressure ulcer observed over client's coccyx region."
"Area of nonblanching erythema noted over client's coccyx, 2 cm × 2 cm."
Which of the following data entries follows the recommended guidelines for documenting data? "Patient kidneys are producing sufficient amount of measured urine." "Patient complained about the quality of the nursing care provided on previous shift." "Following oxygen administration, vital signs returned to baseline." "Patient is overwhelmed by the diagnosis of pancreatic cancer."
"Following oxygen administration, vital signs returned to baseline."
Which of the following examples of documentation best exemplifies sound clinical documentation practices? "Client is anxious during questioning regarding health history and family history." "Abnormal chest sounds noted during posterior chest auscultation." "Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." "Client reports sharp pain to chest on deep inspiration."
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write "after listening to client's lung sounds, both lungs appeared clear." "client's lung sounds were auscultated with stethoscope and were clear on both sides." "bilateral lung sounds clear." "the client's lung sounds were clear on both sides."
"bilateral lung sounds clear."
A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR?
A record supplied by a physician in which diagnoses and prescribed treatments are recorded
The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC? Assessment data in the medical record Client and family requests Medical diagnosis Standards of nursing care
Assessment data in the medical record
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for quality assurance purposes? Reimbursement for care provided Evaluate nursing care provided Evidence in a situation of wrongdoing Discharge planning for the patient
Evaluate nursing care provided
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients:
Have the right to copy their health records.
A computerized risk assessment report correlates data and provides scores on various aspects of clients in the health care facility. Why would this be beneficial for client care?
Notifies health care providers when clients show clinical signs of deterioration
A client is being discharged home. The discharge note that the nurse writes for this client provides information for what purpose? Resources and strategies for managing the client at home Maintaining an accurate list of medications the client has taken Information that is only useful for an internal audit A summary of the medical course of the client while in the hospital
Resources and strategies for managing the client at home
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 nursing implementing?
SOAP charting
A nurse has completed an assessment of a client with cholecystitis and is about to document the findings. Which statement best reflects accurate documentation? Client was interviewed about previous history of hypertension. Skin pale, warm, and dry without evidence of lesions. Client's oral intake and output are satisfactory. Client appears upset about upcoming surgery.
Skin pale, warm, and dry without evidence of lesions.
The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? Vulnerability to legal liability since the nurse's safe, routine care is not recorded. Significant differences in charting between nurses due to lack of standardization. Failure to identify an record patient problems and associated interventions. Increased workload for nurses in order to complete necessary documentation.
Vulnerability to legal liability since the nurse's safe, routine care is not recorded.
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situation
When communicating a patient's change in condition to the patient's physician.
Which patient medical record does the nurse consult when determining activity orders for the patient?
computerized provider order entry
A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical record to check the current medical diagnosis? Demographic data sheet Progress notes Admission history Medication record
progress notes
The nurse completes documentation for a client. Which statement should be questioned? Apical heart rate 88 and regular Dressing on lower leg has some purulent drainage Bowel sounds present all 4 quadrants 24/minute Client reports pain as a 4 on a scale from 1 to 10
Dressing on lower leg has some purulent drainage
There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many health care providers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite?
Improved continuity of care
A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes? It replaces the client acuity classification system. It directly formulates the nursing diagnoses. It creates a data base for care that was not rendered to the client. It provides a chronologic source of client assessment data.
It provides a chronologic source of client assessment data.
A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use?
Nursing minimum data set
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? Asking the client whether his exercise habits have changed recently Repeating the measurement with a different sphygmomanometer and stethoscope Asking the physician to come in and take the client's blood pressure Asking the client whether his diet has changed in the past year
Repeating the measurement with a different sphygmomanometer and stethoscope
Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse? PIE charting Problem-oriented medical record Focus charting Charting by exception
Charting by exception
While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information?
Client denies prior hospitalizations and surgeries
A hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met? Increase interdisciplinary collaboration in the hospital. Eliminate the use of verbal handoffs between nurses. Increase the use of electronic health records (EHRs) in the hospital. Expand the use of the Nursing Minimum Data Set.
Increase the use of electronic health records (EHRs) in the hospital.
A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use? Nursing minimum data set Open-ended forms Cued or checklist forms Integrated cued checklist
Nursing minimum data set
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? "Patient is guarding her abdomen and occasionally moaning." "Patient complaining of abdominal pain rated 8/10." "Patient has a history of recent abdominal pain." "2 mg Dilaudid PO administration with good effect."
"Patient complaining of abdominal pain rated 8/10."
