Question 1

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

Accepted Answer

The Joint Commission recommends that certain words are written out instead of using symbols and abbreviations to minimize the risk of medication errors.The trailing zero should not be used in medication prescriptions; thus,10.0 mg is incorrect.It should be correctly written as 10 mg.The word daily should be used in place of qd or q.d.,as is done in all the options.The Joint Commission does not support the lack of a leading zero; thus,0.3 mg is correctly written.

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?

Accepted Answer

The advance directive,which should be located in a special section of the patient's medical record,should be examined first because the patient's symptoms indicate that he may need to be resuscitated.The advance directive contains information about the patient's wishes for intensity of care and actions that should be taken in the event of a life-threatening event.The discharge plan contains data from utilization review,case managers,or discharge planners on anticipated needs after discharge.Graphic data record assessment should be done frequently,such as vital signs.The history and physical examination provide a detailed summary of the patient's current problem,past medical and social history,medications taken by the patient,review of systems,and physical examination data.

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?

Accepted Answer

The Minimum Data Set for Resident Assessment and Care Screening (MDS)must be updated every 3 months,unless there is a significant change in the resident's condition.

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:

Accepted Answer

The student nurse should question the instruction to use apothecary units-instead of metric units.Nurses are encouraged to use metric units instead of the rarely used apothecary system.

Question 5

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

Accepted Answer

Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS)within 14 days of admission to a long-term care facility.SBAR is a technique used for communicating and organizing a handoff report.HCFA guidelines govern home healthcare documentation.Joint Commission guidelines do apply to long-term care facilities.However,only the MDS assessment is mandated by federal law.

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?

Accepted Answer

Occurrence reports are used to track problems and identify areas for quality improvement.Occurrence reports are not used to provide legal information should a patient seek legal action.As an internal communication and documentation tool,occurrence reports are not required to be reported to the FDA or The Joint Commission.

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?

Accepted Answer

Narrative charting is a free text description of the patient status and nursing care,not usually organized according to patient problems.Focus charting highlights the patient's concerns,problems,and strengths in a three-column format.Source-oriented record systems require members of each discipline to record their findings in a separately labeled section of the chart.A problem-oriented record system is organized around the patient's problems and each member of the healthcare team document in the area designated for that problem.This method makes it easier to view the patient's progress and integrate the interdisciplinary perspective.

Question 8

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

Accepted Answer

The SBAR technique is used as a mechanism to give a handoff report by enabling a focused communication between healthcare team members.DAR is used in Focus Charting®,SOAP is a method for documenting nursing care.The nursing admission assessment is completed and documented at the time of admission.

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?

Accepted Answer

Federal regulations require that a resident be evaluated using the Minimum Data Set within 14 days of admission to a long-term care facility.

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?

Accepted Answer

The nurse should repeat the order to the prescriber even if she believes she understood it entirely.If possible,she should have a second nurse (not the unit secretary)listen to the order to verify accuracy.Only the prescribing provider,not the pharmacist,can verify the order.The nurse should transcribe the order directly on the patient's chart.Transcribing it on a piece of paper and then copying it again introduces one more chance of error.

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:

Accepted Answer

A major disadvantage of CBE is that it can result in omissions in documenting client care because of either varying views of what is abnormal or deviations.Another disadvantage is that is does not capture the application of critical thinking by the nurse in the provision of care.CBE reduces the amount of time spent in charting because if nurses document only deviations from the normal CBE,then it is assumed that unless a separate entry is made,all standards have been met with a normal response.

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?

Accepted Answer

The prescriber must countersign all verbal and telephone orders within 24 hours.

Question 13

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

Accepted Answer

The PIE charting format organizes information by the client's problems and requires a daily assessment record and progress notes,thus eliminating the need for a nursing care plan.It documents,in a comprehensive manner,the client information.It does not assess the client.

Question 14

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

Accepted Answer

"Patient refuses the 0900 dose of digoxin" objectively describes the event in which the patient refuses to take his 0900 dose of digoxin."0900 dose of digoxin not given," provides no explanation why the medication was not given.The other two options offer judgmental information,which should be avoided when charting.

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?

Accepted Answer

Correct documentation of a telephone order is as follows: "09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr.D.Kelly/Kay Andrews,RN" (date,time,medication,route,frequency of dose,circumstances under which it is to be given,prescriber's name and title,nurses name and title.)The other options demonstrate incomplete documentation of a telephone order.

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:

Accepted Answer

OOB is the abbreviation for "out of bed." The nurse is following the physician's order when she assists the patient out of bed in the morning.OOB does not indicate that the nurse should perform oral care,assist with bathing,or change the patient's postoperative dressings.

Question 17

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

Accepted Answer

One of the most beneficial aspects of electronic documentation systems is its ability to improve legibility,which reduces the risk for medication administration and other errors.Electronic documentation systems also assist collaboration,provide cautionary reminders about possible adverse reactions,and serve as a resource; but these are not the most beneficial aspects.

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?

Accepted Answer

The postoperative colon resection integrated plan of care should be followed; however,modifications should be made to meet the patient's other health needs.Therefore,portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection plan of care,or individualized nursing diagnoses and interventions may be integrated into the plan.

Question 19

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

Accepted Answer

A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart.The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list.Narrative charting allows the nurse to provide information in a disorganized 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.

Accepted Answer

Charting must be accurate and succinct.Only chart what you observe.Do not chart what others have observed as your own observation.Avoid judging patients; instead,chart objectively.

Quiz 18: Documenting Reporting