Socialization Final

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?

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

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states:

Although not written, the nurse must know or question the rationale before performing an action. Although the scientific rationale is not documented in the clinical plan, it is no less important than in the instructional plan. Nurses and other members of the healthcare team must know the rationale behind the intervention or must question and review the rationale before performing the action

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?

Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

What nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"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." SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse?

"I will have to review the policy that determines what procedure is in place for client access." Clients have the right to see their own medical records and request changes to documentation that may be in error. Most facilities have a policy in place for the client to obtain medical records and the nurse should ensure that the policy is followed by being familiar with that policy prior to giving the client free access to the record. The nurse should not demean the client by assuming that the information may be confusing. The nurse should not allow the client access to the computer while using the nurse's password or login information. While the hospital maintains responsibility for the record, the client has the right to see it.

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records." The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?

Graphic sheets The graphic record 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. Flow sheets are documentation tools used to efficiently record routine aspects of nursing care, not data as asked in the question. The purpose of progress notes is to inform caregivers of the progress a client is making toward achieving expected outcomes. The medical record is a general term for all of the client's medical information, which would include progress notes, flow sheet, and graphic sheets, to name a few.

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation?

Source-oriented A source-oriented record 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, with the most recent entry being nearest the front of the record. Problem-oriented medical record (POMR) or problem-oriented record is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. PIE charting system is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this documentation system, a client assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets). Client problems identified in these assessments are numbered, documented in the progress notes, worked up using the problem, intervention, evaluation (PIE) format, and evaluated each shift. 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 narrative notes.

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?

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.