Question 1

While discussing confidentiality policies and laws protecting client records,a student asks why it is acceptable for them to have access to client records in the clinical area.What is the correct rationale for this?

Accepted Answer

Students are allowed access to client records for the purpose of learning, but it is still their responsibility to maintain confidentiality and privacy laws. The rationale for this is that students need to learn how to properly document and manage client information, which is an essential part of their education as healthcare professionals.

Question 2

Documentation arranged in a chronological order,from the time the nurse started the shift until the nurse entered the documentation in the client's record,is an example of which of the following?

Accepted Answer

Narrative charting is a method of documentation that involves recording information about a patient's care in chronological order, detailing the events as they happen from the beginning of the nurse's shift until the documentation is entered. This method allows for a comprehensive and continuous account of the patient's condition and the care provided.

Question 3

A client did not meet the goal of walking independently,without assistive devices,by discharge.The case manager,using a critical pathway,would identify this as which of the following?

Accepted Answer

A variance is a deviation from the expected outcomes or goals in a critical pathway. In this case, the client not meeting the goal of walking independently without the use of assistive devices is a variance, indicating that the expected outcome was not achieved.

Question 4

A cardiac specialty hospital has several written plans in place according to specific medical diagnoses.Typical nursing diagnoses as well as standard nursing interventions are included in these plans.This hospital is utilizing which of the following?

Accepted Answer

The scenario describes a hospital that has written plans for specific medical diagnoses that include nursing diagnoses and interventions. This is characteristic of standardized care plans, which are pre-written plans of care for specific diagnoses or conditions. Traditional care plans are individualized plans of care created for each patient. Critical pathways are similar to standardized care plans but include time frames for each intervention. Kardex is a type of tool used for organizing patient information but does not include pre-written plans of care.

Question 5

Liam,19,is brought to the emergency department by police.There are numerous large areas of bruising around his throat and upper arms,his upper lip is cut,and his clothes are ripped.What is the most appropriate documentation for this situation?

Accepted Answer

This choice provides clear and concise documentation of Liam's injuries, including the location and size of the bruises and the fact that his clothes were ripped. It also notes that he was brought to the ED by police, which is important information for the medical record. The other choices are either incomplete or use vague language that does not accurately describe Liam's injuries.

Question 6

A nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording.When searching for the most recent physician's orders,the nurse should look in which section?

Accepted Answer

In problem-oriented medical records, the plan of care section contains the most recent physician's orders.

Question 7

Nursing students must thoroughly research information about their assigned clients in order to provide appropriate and safe care during their clinical experiences.In order to help students save time in researching all of this information,what should be their first place to start the review?

Accepted Answer

The answer of Nursing students must thoroughly research information about...

Question 8

Which of the following statements best describes focus charting?

Accepted Answer

Focus charting organizes progress notes by data, action, and response. This helps to identify the client's concerns and how they were addressed through nursing interventions. Option A is incorrect because focus charting allows for documentation of a variety of client problems, both physiological and psychosocial. Option B is incorrect because exceptions to norms are documented in the DAR (data, action, response) format, but other necessary charting is still completed. Option C is incorrect because flowsheets can still be used in conjunction with focus charting.

Question 9

Which of the following types of information would be most informative and should be given in the change-of-shift report?

Accepted Answer

The information about voiding 400 mL of yellow urine 4 hours after catheter removal is important as it indicates the client's urinary function and the effectiveness of the catheter removal. The other options provide basic information but are not as informative or relevant.

Question 10

Under which category of SOAP charting would the nurse look to determine whether or not a client had reported having nausea?

Accepted Answer

Subjective data refers to information that the client reports or feels, such as symptoms like nausea.

Question 11

Michalea,a nursing student,discovers that she has written in the wrong chart.What is the correct action to take?

Accepted Answer

Drawing a line through the entry and writing "mistaken entry" followed by the initials ensures that the mistake is acknowledged and can be easily identified by other healthcare providers. It also keeps the original documentation intact for future reference, should it be necessary. Using correction fluid or blackening out the documentation can be seen as an attempt to hide the mistake and can lead to legal and ethical issues. Striking an "X" through the page is also not recommended as it can be confused with a completed or cancelled order.

Question 12

The nurse responds to a client's call light.When entering the room,the nurse sees that the client is lying on the floor,with the bed linens around his legs.Which of the following would be the most correctly written chart entry?

Accepted Answer

Option C is the most objective and accurate chart entry as it simply states the facts observed by the recorder. Option A and B include subjective assumptions about how the client fell, while option D suggests the client pushed the call button for assistance, which contradicts the scenario described in the question.

Question 13

The client states,"I do not want anyone to visit me who has not been cleared through me first." If utilizing the SOAP format,this statement would be documented under which category?

Accepted Answer

The client's statement is a subjective piece of information and reflects their preferences and concerns. This information would be documented under the subjective data category in the SOAP format. Planning would involve developing a plan of care in response to the client's preferences, assessment would involve evaluating the client's overall health and well-being, and objective data would involve observable and measurable information such as vital signs or physical assessments.

Question 14

A nurse administers analgesic medications to a client through a central line.This information should be documented in which section if using PIE charting?

Accepted Answer

The administration of analgesic medications would fall under the Intervention section of PIE charting as it is an action taken by the nurse to address a problem or issue with the client's care.

Question 15

Mr.Suzuki,79,is deteriorating but remains alert and oriented.Three days after admission,he tells his nurse,"I am tired of being sick.I wish I could end it all." What is the most accurate and informative way to record this data in the progress notes?

Accepted Answer

This option is the most accurate and direct in quoting Mr. Suzuki's exact statement, ensuring clear communication to all healthcare providers involved in his care. The other options may be interpreted differently and may not fully capture the severity of the situation. It is important to document exact quotes to ensure accurate communication and appropriate interventions.

Question 16

A nurse charts,"NG tube irrigated with 25 mL of normal saline." For the focus charting method,which category would be appropriate for this entry?

Accepted Answer

This entry describes an action taken by the nurse (irrigating the NG tube), so it would fit under the "Action" category in focus charting.

Question 17

A nurse returns to work following a vacation and is assigned to new clients.Where can the nurse quickly find accurate,up-to-date information on each client?

Accepted Answer

The Kardex contains the most up-to-date information on each client and is a quick reference for the nurse. The previous nurse's worksheet may contain some information but may not be complete or accurate. The admission sheet may not reflect changes in the client's condition or plan of care. A computer printout of the hospital census may not provide detailed information on each client.

Question 18

A client has specific cultural needs in regards to the plan of care.This information would be found in which of the following?

Accepted Answer

The answer of A client has specific cultural needs in...

Question 19

The client,after receiving emergency treatment for an acute asthma attack,had diminished wheezing in both lungs.When utilizing focus charting,this information would be included in which section?

Accepted Answer

The answer of The client,after receiving emergency treatment for an...

Question 20

At the end of the shift,the nurse is reviewing client documentation.Among the chart entries,special attention is paid to the flow sheets and abnormal assessment findings for each client.This type of charting is an example of which of the following?

Accepted Answer

Charting by exception is a system in which only significant or abnormal findings are documented, freeing up more time for the nurse to provide direct care to the patient. This type of charting also allows for quicker identification of any potential problems or changes in the patient's condition. The nurse's focus on the flow sheets and abnormal assessment findings for each client suggests that they are using charting by exception.

Quiz 24: Documenting and Reporting