Question 1

A client's condition has deteriorated and the nurse needs to notify the health care provider.What information should the nurse include when providing a telephone report on this client?
Standard Text: Select all that apply.
A)Client's medical diagnosis
B)Name of unit nurse manager
C)Names of family members visiting
D)Name and relationship to the client
E)Observed changes in the client's status

Accepted Answer

The answer of A client's condition has deteriorated and the...

Question 2

The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client care.Which actions should the nurse take to prove adherence?
Standard Text: Select all that apply.
A)Charting the client's response to pain medication taken
B)Describing the client as "appearing to be comfortable"
C)Leaving sufficient charting space for the previous shift to chart client teaching
D)Documenting that the client reports,"I'm so afraid of tomorrow's surgery"
E)Making a late entry regarding a client's request for pain medication

Accepted Answer

Charting the client's response to pain medication taken (A), documenting the client's statement about being afraid of tomorrow's surgery (D), and making a late entry regarding a client's request for pain medication (E) are all important elements of accurate and timely documentation that meets legal and ethical standards. Describing the client as "appearing to be comfortable" (B) is subjective and may not provide a clear indication of the client's actual condition. Leaving sufficient charting space for the previous shift to chart client teaching (C) is important for continuity of care but does not provide direct evidence of adherence to practice guidelines.

Question 3

The nurse is using I-SBAR to provide a report to an intensive care nurse for a client transfer.Which statements indicate that the nurse is using this communication technique appropriately?
Standard Text: Select all that apply.
A)"Mr.Collins has a history of peptic ulcer disease."
B)"Hi Susan,my name is Janie and I've been taking care of Mr.Collins all day."
C)"It's no wonder he's bleeding from his stomach;he drinks a six pack of beer every day."
D)"Late this morning Mr.Collins became nauseated and vomited 250 mL of bright red emesis."
E)"He has bowel sounds in all 4 quadrants,is not experiencing any pain,but has a heart rate of 110 and blood pressure of 98/50 mm Hg."

Accepted Answer

The answer of The nurse is using I-SBAR to provide...

Question 4

The nurse is documenting care provided to a client.Which action should the nurse take to demonstrate the avoidance of potentially confusing abbreviations when documenting?
Standard Text: Select all that apply.
A)Documenting vital signs as "TPR."
B)Charting that the "drsg was dry and intact."
C)Transcribing a verbal order as "Carbamazepine 12 mcg/ml IV push daily."
D)Documenting "Client consistently requesting IM MS for pain well before prescribed time."
E)Charting,"Client to be ambulated q.i.d."

Accepted Answer

The answer of The nurse is documenting care provided to...

Quiz 15: Documenting and Reporting

A client's condition has deteriorated and the nurse needs to notify the health care provider.What information should the nurse include when providing a telephone report on this client? Standard Text: Select all that apply.

The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client care.Which actions should the nurse take to prove adherence? Standard Text: Select all that apply.

The nurse is using I-SBAR to provide a report to an intensive care nurse for a client transfer.Which statements indicate that the nurse is using this communication technique appropriately? Standard Text: Select all that apply.

The nurse is documenting care provided to a client.Which action should the nurse take to demonstrate the avoidance of potentially confusing abbreviations when documenting? Standard Text: Select all that apply.