Deck 10: Healthcare Team Communication: Documenting and Reporting

Question 1

What ensures continuity of care?

A) Reassessment
B) Critical thinking
C) Communication
D) Integration

Answer 1

Communication

Question 2

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

A) Dialogue
B) Documentation
C) Reporting
D) Verification

Answer 2

Reporting

Question 3

How can a nurse obtain additional information about a client?

A) Read the client's history and assessment.
B) Call the client's family.
C) Ask the client's sister about the family history.
D) Review nursing literature.

Answer 3

Read the client's history and assessment.

Question 4

What dual purpose does an audit serve?

A) Communication and evaluation
B) Knowledge and quality
C) Education and confidentiality
D) Quality assurance and reimbursement

Question 5

A nurse is working as a case manager, and in this role, he or she audits charts. Audits of client records are performed primarily for quality assurance and:

A) reimbursement.
B) staff development.
C) research.
D) change of mechanisms.

Question 6

Which organization audits charts regularly?

A) The Joint Commission
B) National League for Nursing
C) American Nurses Association
D) Sigma Theta Tau International

Question 7

Besides being an instrument of continuous client care, the client's medical record also serves as a(an):

A) assessment tool.
B) legal document.
C) Kardex.
D) incident report.

Question 8

How can the nurse researcher obtain information from a client record?

A) Audit discharge records
B) Interview nursing staff
C) Examine institutional procedures
D) Study client records

Question 9

Which principle should guide the nurse's documentation of entries on the client's medical record?

A) Correcting fluid is used rather than erasing errors.
B) Documentation does not include photographs.
C) Precise measurements should be used rather than approximations.
D) Nurses should not refer to the names of physicians.

Question 10

When a nurse recognizes having documented one client's assessment data on the wrong client's medical record, the nurse should:

A) draw a single line through the error, and initial it.
B) use a felt tip pen to cover the error.
C) use white out to cover the error.
D) replace the record, rewriting the error.

Question 11

A new graduate is working at the graduate's first job. Which statement is most important for the new nurse to follow?

A) Use abbreviations approved by the facility.
B) Document lengthy entries using complete sentences.
C) Use PIE charting even if it is not the institution's charting method.
D) Only document changes in the client's status.

Question 12

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining:

A) subjectivity.
B) objectivity.
C) organization.
D) reimbursement.

Question 13

Which characteristic of a nurse's charting will assist most in the avoidance of errors?

A) Detail
B) Brevity
C) Subjectivity
D) Timeliness

Question 14

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is:

A) no other charting method is necessary.
B) access is open to anyone.
C) retrieval of information is more efficient.
D) it is less costly to maintain.

Question 15

A client's record can be more accurate if the nurse:

A) charts at least every 6 hours.
B) uses point-of-care documentation.
C) summarizes client care at the end of the shift.
D) delegates charting appropriately.

Question 16

During a client's hospitalization, the client has developed shortness of breath, with edema. What action should the nurse take?

A) Review the nursing care plan.
B) Implement changes in the current interventions.
C) Involve the family in changes.
D) Revise the plan of care.

Question 17

A concise document that provides most of the client's nursing and medical information is a(n):

A) nursing care plan.
B) Kardex.
C) past chart.
D) office record.

Question 18

Charting in which the nurse writes a progress note that relates to one health problem is a:

A) PIE note.
B) Flow sheet.
C) Narrative note.
D) SOAP note.

Question 19

Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss?

A) Vital sign sheet
B) Intake and output sheet
C) Critical care flow sheet
D) Health assessment flow sheet

Question 20

The nurse is caring for a client with uncontrolled hypertension. His or her blood pressure has remained controlled for the nurse's shift. At 2-hour intervals, the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the client has a stroke. Years later, the client files a lawsuit blaming the hospital for the stroke. The nurse who was caring for the client when the client's blood pressure was stable cannot recall the exact blood pressure readings obtained, but remembers it was normal. Will this recollection suffice in court and why?

A) Yes, the nurse remembers the pressure as normal during his or her shift and can swear to it during the deposition.
B) No, but it will relieve the nurse of any wrongdoing.
C) No, if the blood pressure measurement was not documented, it did not happen.
D) Yes, the nurse was not on duty when the stroke occurred.

Question 21

The client record is utilized for many purposes. Which might be a use for the client record? Select all that apply.

A) Education of student nurses
B) Reimbursement for services
C) Research
D) Giving information over the phone when unidentified callers call the hospital unit
E) Education for medical students

Question 22

The federally initiated goal of computer-based personal records would likely produce which of the following benefits? Select all that apply.

A) Access to records outside of the client's home facility
B) Increased accuracy of treatment for the client outside their home facility
C) Easier access to data for research
D) Increased incidence of identity theft
E) Greater accuracy and improved client care

Question 23

Which entry should the nurse include when charting? Select all that apply.

A) The nursing assistant reports the client's breath smelled of alcohol.
B) I feel something is going on he or she is not telling me.
C) The client was overheard telling his or her family about more bleeding than he or she has reported to his or her physician.
D) The incision is oozing a small amount of red blood.
E) The client's pupils are dilated.

Question 24

Which statement describes best practices for charting? Select all that apply.

A) Use long narratives to be sure your documentation is understood.
B) Always use complete sentences.
C) Use only approved abbreviations.
D) Always use the client's name and words referring to the client in each entry.
E) Use partial sentences and phrases.

Question 25

The client states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." The client's arms are folded across the chest. The brow is furrowed and the client refuses to allow morning vital sign measurements. Which entry should be included in the nurse's charting? Select all that apply.

A) Seems angry today.
B) Unhappy with his or her care.
C) Arms are folded across his or her chest and brow is furrowed.
D) States, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today."
E) Refuses to allow morning vital sign measurements.

Question 26

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which information should the nurse record in his or her charting? Select all that apply.

A) Client is crying.
B) Client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today."
C) Client seems depressed.
D) Client is suicidal.
E) Client is in a bad mood.

Question 27

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in his or her charting?

A) "If I make an error, I can draw a red circle around it."
B) "If I make an error, I have to rewrite the entire entry."
C) "If I make an error, I draw a single line through it and put my initials by it."
D) "If I make an error, I place an X through it."
E) "If I make an error, I use white-out on it."