Deck 18: Documenting Reporting

Question 1

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?
1)09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN
2)09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. TO Dr. D. Kelly/Kay Andrews, RN
3)09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. VO Dr. D. Kelly/Kay Andrews, RN
4)09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. VO Kay Andrews, RN

Answer 1

2

Question 2

Which set of topics makes up a handoff report given in a recommended format?
1)Data-action-response (DAR)
2)Subjective-objective-assessment-plan (SOAP)
3)Situation-background-assessment-recommendation (SBAR)
4)Flowsheets-assessment-concise-timely (FACT)

Answer 2

3

Question 3

The unlicensed assistive personnel (UAP) 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.
1)Patient found on floor after falling out of bed and verbalizes (L) hip pain.
2)Patient found on floor by UAP Smith and verbalizing (L) hip pain.
3)Patient fell out of bed but is currently in bed.
4)Patient reminded not to climb OOB after falling.

Answer 3

2

Question 4

A resident being admitted to a long-term care facility is unable to provide self-care due to dementia and is receiving Medicare funds. At which time must the Resident Assessment and Care Screening be completed?
1)Within 2 weeks
2)Each shift
3)Every week
4)When the provider orders it

Question 5

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?
1)Repeat the order to the prescriber, even if the nurse believes the order was understood correctly.
2)Immediately notify the pharmacy of the order, and verify it with a pharmacist.
3)Ask the unit secretary to listen to the prescriber on the phone to verify the order.
4)Transcribe the order on notepaper, and verify the dosage in a drug handbook.

Question 6

A client is admitted to a long-term care facility. The nurse would use which form to follow federal law?
1)The Minimum Data Set (MDS) for assessment
2)Situation-Background-Assessment-Recommendation (SBAR) for reporting
3)Health Care Financing Administration (HCFA) guidelines prior to surgery
4)The Joint Commission guidelines for discharge planning

Question 7

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system?
1)It involves a cooperative effort among various disciplines.
2)The system requires diligence in maintaining a current problem list.
3)Data may be fragmented and scattered throughout the chart.
4)Oversights of care may result from disagreement over what constitutes a significant variation.

Question 8

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; the client is cyanotic (turning blue) with periods of labored breathing. Which action should the nurse take first?
1)Study the discharge plan.
2)Check the progress notes for vital signs.
3)Examine the history and physical examination.
4)Look for an advance directive.

Question 9

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates correct understanding of the purpose of occurrence reports?
1)"These reports track problems and identify areas for quality improvement."
2)"These reports are required by the Food and Drug Administration (FDA) to report drug errors."
3)"These reports are required by The Joint Commission for all client falls."
4)"These reports provide legal information should the patient seek legal action after an unusual occurrence."

Question 10

Which charting entry would the nurse use for the "A" in SOAP charting?
1)Intractable pain
2)"I can't get any relief from this pain in my abdomen."
3)Holding abdomen and moaning
4)Notified provider to change pain medication.

Question 11

A student nurse makes the following comments to the 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?
1)Narrative
2)Focus
3)Source-oriented
4)Problem-oriented

Question 12

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 priority for the nurse to implement?
1)Hypertension
2)Rheumatoid arthritis
3)Postoperative colon resection
4)Diabetes mellitus

Question 13

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 the nurse is following the surgeon's order?
1)Performs oral care
2)Assists the patient out of bed
3)Helps the patient with bathing
4)Changes the patient's operative dressings

Question 14

What is one advantage of problem-intervention-evaluation (PIE) charting?
1)Focuses on a complete list of client problems
2)Assesses the client in a comprehensive manner
3)Documents the planning portion of the client's care
4)Establishes an ongoing plan of care for the client

Question 15

At 1000 on 11/14/19, 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?
1)11/14/19 at 1200
2)11/14/19 at 2200
3)11/15/19 at 1000
4)11/16/19 at 1000

Question 16

Which aspect is the most beneficial for electronic documentation systems when compared with written documentation systems?
1)Assists collaboration
2)Provides different terminology
3)Improves legibility
4)Serves as a resource

Question 17

Which instruction by a registered nurse should the student nurse clarify with the clinical instructor about transcribing the provider's orders?
1)"Write drug names in full-rather than using abbreviations."
2)"Use apothecary units-instead of metric units."
3)"Use 'at' or 'each'-rather than use the '@'symbol."
4)"Write 'mL' or 'milliliters'-in place of the 'cc' abbreviation."

Question 18

A patient refuses a dose of medication. How should the nurse document the event?
1)Patient is uncooperative and refuses the prescribed dose of digoxin.
2)Patient refuses the 0900 dose of digoxin.
3)Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. 4.0900 dose of digoxin not given.

Question 19

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which example would be a major disadvantage of CBE?
1)Increases the time nurses spend on charting in narrative format
2)Does not clearly identify deviations from normal expectations
3)Requires all providers to document in the same sections of the chart
4)Can increase the risk of omissions in client care

Question 20

Which prescription would the nurse question since it is inconsistent with the standards established by The Joint Commission?
1)Administer Lasix 20 mg PO daily at 1000.
2)Administer Lasix 10.0 mg PO daily at 1000.
3)Administer digoxin 10 mg PO daily at 1000.
4)Administer digoxin 0.3 mg IV daily at 1000.

Question 21

Which points regarding discharge summaries must the nurse remember? Select all that apply.
1)The discharge summary is important because clients require follow-up care.
2)A complete discharge summary is a guide for healthcare professionals in the community.
3)The nurse can give a verbal transfer report, which is the same as a discharge summary.
4)The discharge summary is the final note in the client's paper record.
5)A complete discharge summary must be handwritten using the narrative note format.

Question 22

A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. Which type of charting is the nurse using?
1)Narrative charting
2)Charting by inclusion
3)Charting by exception
4)Source-oriented charting

Question 23

Which actions by the nurse breach patient confidentiality? Select all that apply.
1)Leaving patient data displayed on a computer screen where others may view it
2)Remaining logged on to the computer system after documenting patient care
3)Faxing a patient report to the nurses' station where the patient is being transferred
4)Informing the nurse manager of a change in the patient's condition
5)Accessing records of patients assigned to the nurse

Question 24

Which statements by the new graduate nurse indicate a need for further instruction about documentation? Select all that apply.
1)"I can wait until the end of the shift to document my care."
2)"Charting every 2 hours is the most appropriate way to document nursing care."
3)"I find it easier to chart before I go to lunch and then after my shift report."
4)"I should chart as soon as possible after nursing care is given."
5)"Charting after performing an intervention is acceptable."

Question 25

The implementation of electronic health records (EHRs) allows the nurse to carry out which actions? Select all that apply.
1)Use data to facilitate evidence-based nursing practice.
2)Promote efficient use of time spent charting.
3)Reduce the opportunity for interdisciplinary collaboration.
4)Activate the system's safeguards to improve quality of care.
5)Access patient information at the same time as other team members.

Question 26

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?
1)Ensures that the nurse is able to finish the shift as quickly as possible
2)Provides a guide for the nurse's report to the oncoming nurse
3)Requires the nurses to engage in walking rounds for the report
4)Offers a detailed cultural report on Latino patients

Question 27

In performing a handoff report, the nurse should communicate information on which parameters? Select all that apply.
1)Teaching performed
2)Any change in client status
3)Treatments administered
4)Hygiene measures performed
5)Insurance status

Question 28

The instructor is teaching the nursing students about electronic health records (EHRs). Which student statement indicates the need for further instruction?
1)"I have had EHR instruction and understand the basics of the system. If I need assistance, I will ask for it."
2)"The EHR integrates the patient's health information documented by the entire healthcare team into one electronic system."
3)"The EHR can track problems and errors, which can direct quality improvement efforts in a given institution."
4)"I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution."

Question 29

Which statements by the student nurse indicates a correct understanding of the nursing Kardex? Select all that apply.
1)"It pulls data from multiple areas of the patient's chart."
2)"It is usually kept at the patient's bedside."
3)"It is used to document patient response to interventions."
4)"It summarizes the plan of care and guides nursing care."
5)"It is a component of the patient's permanent health record."

Question 30

Why might a healthcare provider choose narrative charting instead of using forms or checklists?
1)Narrative charting tracks the client's changing health status as it occurs.
2)Free form documentation is inconsistent among healthcare providers.
3)Less charting time by healthcare provider is needed for narrative charting.
4)Less interdisciplinary discussion occurs with the narrative style of charting.

Question 31

A medical provider has prescribed milk of magnesia (magnesium hydroxide) 30 mL, PO bid. What does bid mean?
1)Once every day
2)Two times every day
3)Three times every day
4)Four times a day

Question 32

The nurse is administering the 0900 dose of heparin (an anticoagulant) 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 (excessively elevated). The nurse observes bruising on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding. Which actions would the nurse take? Select all that apply.
1)Notify the prescriber.
2)Give subcutaneous heparin, as ordered.
3)Hold the medication dose at this time.
4)Chart the reason the medication was not given.
5)Record abnormal findings in the patient's health record.

Question 33

The electronic health record (EHR) is used to document client care. Which purposes are applicable to the EHR? Select all that apply.
1)Is a legal record
2)Is used for utilization review
3)Provides continuity of care
4)Is used for quality improvement
5)Acts as an occurrence report