PrepU Documentation
6. To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for? a. Reinforcing data b. Response c. Recommendations d. Report
Answer 6: c. Explanation: SBAR stands for Situation, Background, Assessment, and Recommendations.
10. A nursing student is attending a clinical rotation in a labor/deliver/postpartum unit and is able to see a vaginal delivery for the first time. The student takes a picture of the newborn and posts it on a social media website. What action may occur related to this privacy violation? a. The student may be dismissed from the nursing program as well as fined for a HIPAA violation. b. No action will be taken as long as the parents don't find out. c. There will be no repercussions if the student takes the picture down from the social media page. d. The student will never be eligible for entry into a nursing program or be able to take the NCLEX.
Answer 10: a. Explanation: The student has committed a HIPAA violation as well as breached the school's social media policy. The student has placed a newborn and family at risk by posting pictures to a social media website where anyone is at liberty to view the page. The student may well be dismissed for this infraction and is at risk for fines and imprisonment for a HIPAA violation. The social media policy should be enforced with violations and consequences explained to all students as well as have them sign a social media policy. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 16: Documenting, Reporting, Conferring, and Using Informatics, p. 362.
1. 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
Answer 1: a. Explanation: 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. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 362.
2. 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
Answer 2: a. Explanation: 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. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 362.
3. What is the primary purpose of the client record? a. Communication b. Advocacy c. Research d. Education
Answer 3: a. Explanation: The primary purpose of the client record is to help health care professionals from different disciplines communicate with one another. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 339.
4. 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.
Answer 4: b. Explanation: A nursing care conference is a meeting of nurses to discuss some aspect of a client's care. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 16: Documenting, Reporting, Conferring, and Using Informatics, p. 363.
5. 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 whose status is stabilized c. a client who is not making progress in expected outcomes of care d. a client who is homebound and needs skilled nursing care
Answer 5: d. Explanation: 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. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 16: Documenting, Reporting, Conferring, and Using Informatics, p. 358.
7. 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 the clients the right to withhold the release of their information to anyone. b. Problem-oriented recording is difficult to demonstrate a unified approach for resolving the clients' problem 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 each member of the multidisciplinary team makes entry about their own specific activities in relation to the client's care.
Answer 7: c. Explanation: Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among healthcare providers is an advantage of problem-oriented recording and is therefore correct. Giving the clients the right to withhold the release of their information to anyone is beneficial disclosure, and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving the clients' problem among caregivers and having numerous locations for information where each member of the multidisciplinary team makes entries about their own specific activities in relation to the client's care are examples of source-oriented recording. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 16: Documenting, Reporting, Conferring, and Using Informatics, p. 353.
8. Which finding from a nursing audit reflects high standards for client safety and institutional health care? a. The nurse records inappropriate nursing interventions. b. The nurse fails to identify the nursing diagnoses or clients' needs. c. The nurse documents clients' responses to nursing interventions. d. The nurse fails to adequately complete data on clients' health history and discharge planning.
Answer 8: c. Explanation: Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by the Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health history and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 16: Documenting, Reporting, Conferring, and Using Informatics, p. 350.
9. To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information? a. failing to recognize the client's right to withhold health information for research b. releasing the client's entire health record when only portions of the information are needed c. failing to obtain the client's signature, indicating that the client was informed of the disclosure of information d. submitting a written notice to all clients identifying the uses and disclosures of their health information
Answer 9: d. Explanation: Submitting a written notice to all clients identifying the uses and disclosures of their health information is correct. The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of health records and the security of that data. Failing to recognize the client's right to withhold health information for research, releasing the client's entire health record when only portions of the information are needed, and failing to obtain the client's signature indicating that the client was informed of the disclosure of information are incorrect, as these are HIPAA violations. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 16: Documenting, Reporting, Conferring, and Using Informatics, p. 340-342.