Question 1

The nurse is teaching medication administration to a client being discharged.Which instruction should the nurse rewrite for this client?

Accepted Answer

A

Question 2

After classroom discussion regarding confidentiality policies and laws protecting client records,a student asks why it's permissible for them to review and have access to client records in the clinical area.How should the nursing instructor respond?

Accepted Answer

The nursing instructor should explain that although students are allowed to review client records for educational purposes, they are still bound to uphold the same strict confidentiality laws and policies that apply to all healthcare professionals. Students must protect the privacy and confidentiality of client information at all times, even when they are using it for learning purposes.

Question 3

After completing the client care and documenting it in the progress notes,the nurse realizes that documentation was placed on the wrong medical record.What should the nurse do?

Accepted Answer

The best option is to draw a single line through the documentation, write "mistaken entry" next to the original entry, and initial it. This is because it clearly shows that an error was made and acknowledges it without trying to cover it up or erase it completely. This ensures that the integrity of the chart is maintained and provides a clear record of what happened. Using white-out or blackening out the documentation can be seen as trying to conceal the mistake, which can compromise the accuracy and trustworthiness of the documentation. Putting an "X" through the page and identifying it as an "error" is also an acceptable option, but adding an initial next to it ensures that the error is attributed to the correct person.

Question 4

A client has specific cultural needs that affect the plan of care.In which part of the client's problem-oriented medical record should the nurse document this information?

Accepted Answer

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

Question 5

A client in long-term care is scheduled for a review of the assessment and care screening process.Where should the nurse document this information?

Accepted Answer

The Minimum Data Set (MDS) is a standardized tool for conducting facility-wide assessments for nursing home residents. It includes a comprehensive assessment of functional capabilities, health status, and other factors that affect resident care planning and quality improvement efforts. Therefore, the nurse should document the review of the assessment and care screening process in the MDS.

Question 6

When attempting to locate recent lab results,the new nurse employee notices that each department has a separate section in the client's chart.Which type of documentation system is the nurse using?

Accepted Answer

In a source-oriented record, each department has a separate section in the client's chart, allowing for easy organization and access to specific information related to that department. This type of documentation system has been used traditionally in healthcare facilities.

Question 7

The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format,in which category should the nurse document this statement?

Accepted Answer

The client's statement is an expression of their personal preference and therefore falls under the category of subjective data. It is not something that can be observed or measured objectively, so it does not fit under objective data. The statement also does not provide any diagnosis or conclusion, so it does not fit under assessment or planning.

Question 8

A hospital is not able to be reimbursed for care a particular client received while in the emergency department.The client came in with chest pain,which was later diagnosed as gastric reflux.Which problem with documentation might have caused the lack of reimbursement?

Accepted Answer

The client's record containing an incorrect Diagnosis-Related Group (DRG) could lead to a lack of reimbursement because DRGs are used to classify hospital cases into groups for the purposes of payment. If the DRG does not accurately reflect the services provided, the hospital may not receive appropriate reimbursement.

Question 9

A cardiac specialty hospital has several written plans in place for clients who are admitted,according to specific medical diagnoses and nursing interventions.Typical nursing diagnoses as well as standard nursing interventions are included in these plans.Which type of form is this hospital utilizing?

Accepted Answer

The hospital is utilizing standardized care plans, which include typical nursing diagnoses and standard nursing interventions for specific medical diagnoses. Critical pathways are similar but involve a more detailed timeline for care delivery, while traditional care plans and Kardex may not be standardized or specific to certain diagnoses.

Question 10

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him,as it's his record.How should the nurse respond to this client's request?

Accepted Answer

The nurse should inform the client that while the original chart is the property of the hospital, he is entitled to have copies of his records. This promotes the client's rights to access to his medical records, while also informing him of the limitations regarding legal ownership of the chart.

Question 11

The nurse working in a hospital that utilizes a charting by exception (CBE)documentation system notes that a client did not require care in all of the areas identified on a flow sheet.What action should the nurse take?

Accepted Answer

Writing N/A on the flow sheet in the areas that are not applicable to that client is the appropriate action for a nurse using a charting by exception (CBE) system. This communicates to other healthcare providers that the client did not require care in that specific area without leaving blank spaces or requiring an extensive explanation. It also helps ensure that all necessary information is recorded in a concise and organized manner.

Question 12

The nurse works at an organization that is installing a new computerized record system.What should the nurse learn that has been implemented to help ensure the security of client records?

Accepted Answer

The answer of The nurse works at an organization that...

Question 13

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

Accepted Answer

The Response (R) section is used to document the patient's response to the nursing interventions, and in this case, the client's diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack would be a response to the nursing interventions provided.

Question 14

The nurse administered analgesic medications to an assigned client via central line.In which section of PIE charting should the nurse document this information?

Accepted Answer

The administration of analgesic medications is an intervention, so it should be documented under the Intervention section of PIE charting.

Question 15

The nurse makes chronological entries in a client's chart that include documentation about the routine care provided,assessment findings,and client problems during a 12-hour shift.Which type of charting is this nurse completing?

Accepted Answer

The nurse is completing narrative charting, where they document a chronological account of the care provided during the shift. Problem-oriented recording involves organizing data by problems, whereas source-oriented recording involves documenting information by the source or provider of the information. A plan of care is a document outlining goals and interventions for a client's care.

Question 16

The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording.In which section would the nurse find the most recent physician orders?

Accepted Answer

In problem-oriented recording, the "Plan of care" section contains the most recent physician orders as it outlines the planned interventions and treatments for the patient's identified problems.

Question 17

Before providing care,the nurse reviews the client's pertinent history,daily treatments,diagnostic procedures,allergies,problems,and other information.Which form should the nurse review to learn all of this information?

Accepted Answer

The answer of Before providing care,the nurse reviews the client's...

Question 18

The nurse is documenting client care on flow sheets that identify abnormal assessment findings.Which type of documentation system is the nurse using?

Accepted Answer

Charting by exception is a documentation system that identifies abnormal assessment findings and significant deviations from the established norms or standards of care. This type of documentation is efficient because nurses only need to document exceptions rather than routine care.

Question 19

When responding to a call light,the nurse finds a client lying on the floor,with the bed linens around the legs.Which chart entry should the nurse document for this finding?

Accepted Answer

The correct choice is C because it objectively describes the situation without making assumptions about how or why the client ended up on the floor. It simply states what was observed upon entering the room.

Question 20

A client did not meet the goal of walking unassisted,without assistive devices,by discharge from rehabilitation.The case manager using a critical pathway should identify this outcome as being which of the following?

Accepted Answer

Since the client did not meet the goal of walking unassisted without assistive devices by discharge from rehabilitation, it is considered a variance from the critical pathway. This means that the desired outcome was not achieved and requires further investigation to determine if any changes need to be made to the care plan or intervention implementation. It does not necessarily mean that the goal was unattainable, an error in care planning, or an error in intervention implementation, as there could be other factors that contributed to the lack of goal attainment.

Quiz 15: Documenting and Reporting