Deck 18: Documenting Reporting

Question 1

Which prescription below is not consistent with the standards established by The Joint Commission?

A) Administer Lasix 20 mg PO daily at 1000.
B) Administer Lasix 10.0 mg PO daily at 1000.
C) Administer digoxin 10 mg PO daily at 1000.
D) Administer digoxin 0.3 mg IV daily at 1000.

Answer 1

Administer Lasix 10.0 mg PO daily at 1000.

Question 2

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure.The client's condition is getting worse; he is cyanotic (turning blue)with periods of labored breathing.What action should the nurse take first?

A) Study the discharge plan.
B) Check the graphic data for vital signs.
C) Examine the history and physical examination.
D) Look for an advance directive.

Answer 2

Look for an advance directive.

Question 3

A resident in a long-term care facility is unable to provide self-care owing to dementia and is receiving Medicare funds.How often must the nurse document this resident's care?

A) Every 2 weeks
B) Every shift
C) Every week
D) Every 3 months

Answer 3

Every 3 months

Question 4

Which instruction by a registered nurse should the student nurse clarify with her clinical instructor? "When taking off the provider's orders,you should:

A) Write drug names in full-rather than using abbreviations"
B) Use apothecary units-instead of metric units"
C) Write 'at' or 'each'-rather than use the '@'symbol"
D) Write 'mL' or 'milliliters'-in place of the 'cc' abbreviation"

Question 5

A client is admitted to a long-term care facility.The nurse knows that federal law requires the use of:

A) The Minimum Data Set (MDS) for assessment
B) Situation-Background-Assessment-Recommendation (SBAR) for reporting
C) Health Care Financing Administration guidelines prior to surgery
D) The Joint Commission guidelines for discharge planning

Question 6

The nursing instructor is teaching the student about occurrence reports.Which statement by the student indicates an understanding of the purpose of occurrence reports?

A) "Occurrence reports track problems and identify areas for quality improvement."
B) "Occurrence reports are required by the Food and Drug Administration (FDA) to report drug errors."
C) "The Joint Commission requires occurrence reports for all client falls."
D) "Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."

Question 7

A student nurse makes the following comments to her preceptor: "I love getting information from the chart.Everything related to the patient's problem is together and addressed by various members of the healthcare team." The student nurse has been introduced to which type of charting system?

A) Narrative
B) Focus
C) Source oriented
D) Problem oriented

Question 8

Which set of topics makes up a handoff report given in a recommended format?

A) Data-action-response (DAR)
B) Subjective-objective-assessment-plan (SOAP)
C) Situation-background-assessment-recommendation (SBAR)
D) Patient-diagnosis-medications-activity

Question 9

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident is of a long-term care facility?

A) 14 days
B) 3 days
C) 2 days
D) 24 hours

Question 10

The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours.Which action must the nurse take to ensure the accuracy of the order?

A) Repeat the order to the prescriber even if she believes she understood the order correctly.
B) Immediately notify the pharmacy of the order and verify it with a pharmacist.
C) Ask the unit secretary to listen to the prescriber on the phone to verify the order.
D) Transcribe the order on notepaper and verify the dosage in a drug handbook.

Question 11

The department of nursing at a local hospital is considering changing to charting by exception (CBE).A major disadvantage of CBE is that it:

A) Increases the time nurses spend on charting in narrative format
B) Does not clearly identify deviations from normal expectations
C) Requires all providers to document in the same sections of the chart
D) Can increase the risk of omissions in patient care

Question 12

At 1000 on 11/14/16,the nurse takes a telephone prescription for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order?

A) 11/14/16 at 1200
B) 11/14/16 at 2200
C) 11/15/16 at 1000
D) 11/16/16 at 1000

Question 13

What is one advantage of problem-intervention-evaluation (PIE)charting?

A) Focuses on a complete list of client problems
B) Assesses the client in a comprehensive manner
C) Documents the planning portion of the client's care
D) Establishes an ongoing plan of care for the client

Question 14

A patient refuses a dose of medication.How should the nurse document the event?

A) Patient is uncooperative and refuses the prescribed dose of digoxin.
B) Patient refuses the 0900 dose of digoxin.
C) Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin.
D) 0900 dose of digoxin not given.

Question 15

The nurse notifies the primary care provider that the patient is experiencing pain.The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain.How should the nurse document this telephone order?

A) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN
B) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN
C) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain V.O.: Dr. D. Kelly/Kay Andrews, RN
D) 09/02/16 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

Question 16

The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer.The order states: OOB in AM.Which action indicates that the nurse is following the surgeon's order? The nurse:

A) Performs oral care
B) Assists the patient out of bed
C) Assists the patient with bathing
D) Changes the patient's operative dressings

Question 17

Which of the following is the most beneficial aspect of electronic documentation systems?

A) Assist collaboration
B) Provide cautionary reminders
C) Improve legibility
D) Serve as a resource

Question 18

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery,a colon resection,for colon cancer.Which integrated plan of care (IPOC)would be most appropriate for the nurse to implement?

A) Hypertension
B) Rheumatoid arthritis
C) Postoperative colon resection
D) Follow all three plans

Question 19

A hospital uses a source-oriented medical record.What is a major disadvantage of this charting system?

A) It involves a cooperative effort among various disciplines.
B) The system requires diligence in maintaining a current problem list.
C) Data may be fragmented and scattered throughout the chart.
D) It allows the nurse to provide information in an unorganized manner.

Question 20

The nursing assistive personnel (NAP)informs the nurse that a patient has fallen out of bed and is in pain.The nurse assesses the patient and provides care.Identify the correct documentation of the fall.

A) Patient found on floor after falling out of bed and verbalizes (L) hip pain.
B) Patient found on floor by NAP Smith and verbalizing (L) hip pain.
C) Patient fell out of bed but is currently in bed.
D) Patient reminded not to climb OOB after falling.

Question 21

Which statement(s)by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply.

A) "I can wait until the end of the shift to document my care."
B) "Charting every 2 hours is the most appropriate way to document nursing care."
C) "I find it easier to chart before I go to lunch, and then after my shift report."
D) "I should chart as soon as possible after nursing care is given."

Question 22

Which action by the nurse breaches patient confidentiality? Select all that apply.

A) Leaving patient data displayed on a computer screen where others may view it
B) Remaining logged on to the computer system after documenting patient care
C) Faxing a patient report to the nurses' station where the patient is being transferred
D) Informing the nurse manager of a change in the patient's condition

Question 23

At the end of a 12-hour shift,the nurse gives a verbal report to the oncoming nurse.This face-to-face reporting,using the acronym "CUBAN," does which of the following?

A) Ensures that the nurse is able to finish the shift as quickly as possible
B) Provides a guide for the nurse's report to the oncoming nurse
C) Requires the nurses to engage in walking rounds for the report
D) Provides a detailed cultural report for Latino patients

Question 24

The nurse is administering the 0900 dose of heparin 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT).At 0800,the patient's laboratory values show partial thromboplastin time (PTT)and clotting times are four times the normal range.The nurse observes petechiae on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding.The correct nursing actions at this time are below.Select all that apply.

A) Notify the prescriber before giving the medication.
B) Give subcutaneous heparin as ordered.
C) Hold the medication dose at this time.
D) Chart the reason the medication was not given.
E) Assess for other significant signs and symptoms.
F) Record abnormal findings in the patient's health record.

Question 25

Which statement(s)by the student nurse indicates an understanding of the nursing Kardex? Select all that apply.

A) "It pulls data from multiple areas of the patient's chart."
B) "It is usually kept at the patient's bedside."
C) "It is used to document patient response to interventions."
D) "It summarizes the plan of care and guides nursing care."

Question 26

In performing a handoff report,the nurse should communicate information on which of the following? Select all that apply.

A) Teaching performed
B) Any change in client status
C) Treatments administered
D) Hygiene measures performed

Question 27

A medical provider has prescribed milk of magnesia (magnesium hydroxide)30 mL,PO bid.Here bid means :

A) Once every day
B) Two times every day
C) Three times every day
D) Four times a day

Question 28

Why might a healthcare provider choose narrative charting instead of using forms or checklists?

A) Narrative charting tracks the client's changing health status as it occurs.
B) Free form documentation is inconsistent among healthcare providers.
C) Less charting time by healthcare provider is needed for narrative charting.
D) Less interdisciplinary discussion occurs with the narrative style of charting.

Question 29

The implementation of electronic health records (EHRs)allows the nurse to do which of the following? Select all that apply.

A) Use trend data to facilitate evidence-based nursing practice
B) Promote efficient use of time spent charting
C) Reduce the opportunity for interdisciplinary collaboration
D) Activate the system's safeguards to promote client safety

Question 30

The electronic health record (EHR)is used to document client care management.Which statement(s)below is/are applicable to EHR? Select all that apply.

A) Increases the potential for breaches in confidentiality
B) Decreases the time spent to complete documentation
C) Minimizes medical errors through use of alert systems
D) Communicates the client's plan of care to the healthcare team

Question 31

Knowing that discharge summary information is integral to the client's ongoing care,which of the point(s)regarding discharge summaries must the nurse be aware? Select all that apply.

A) The discharge summary is important because many clients require follow-up care.
B) A complete discharge summary is a guide for healthcare professionals in the community.
C) The nurse can give a verbal transfer report, which is the same as a discharge summary.
D) The discharge summary is the final note in the client's health record
E) A complete discharge summary must be handwritten using the narrative note format.

Question 32

A client is admitted to the birthing unit to rule out preterm labor.The nurse charts only abnormal findings.This type of charting is a form of:

A) Narrative charting
B) Charting by inclusion
C) Charting by exception
D) Source oriented charting

Question 33

The instructor is teaching the nursing students about electronic health records (EHR).Which student statement indicates the need for further instruction?

A) "I have had EHR instruction and understand the basics of the system. If I need assistance, I will ask for it."
B) "The EHR integrates the patient's health information documented by the entire healthcare team into one electronic system."
C) "The EHR can track problems and errors, which can direct quality improvement efforts in a given institution."
D) "I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution."