Question 1

The department of nursing at a local hospital is considering changing to charting by exception (CBE).Which statement provides a rationale to support making this change?

Accepted Answer

Charting by exception (CBE) allows nurses to document only significant deviations from the norm, reducing the time spent on documentation. This time can be better spent providing direct patient care.

Question 2

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

Accepted Answer

A source-oriented medical record can result in fragmented and scattered data throughout the chart because information is organized according to the source that provided it (e.g. nursing notes, physician notes, laboratory results). This can make it difficult to get a comprehensive view of the patient's condition and treatment.

Question 3

The nurse administers heparin 5,000 units subcutaneously at 2100 and documents in the medication administration record (MAR)that the dose was administered.What other information is important for the nurse to document?

Accepted Answer

It is important for the nurse to document the injection site to ensure proper rotation of sites and to monitor for any adverse reactions or complications at the injection site. The other options may be important to document in certain situations, but they are not necessary for routine documentation of a subcutaneous heparin injection.

Question 4

A client is admitted to a long-term care facility.What does the nurse have to use to adhere to federal law?

Accepted Answer

The Minimum Data Set (MDS) is a federally mandated tool for comprehensive assessment of residents in long-term care facilities. It is used to determine each resident's physical, cognitive, and psychosocial functioning and guide care planning. Adhering to this tool is necessary to comply with federal law.

Question 5

The patient's medical record contains the following documentation: 06/05/17 0200 Received patient from the E.D.BP 80/52,HR 118,RR 24,temp 104°F.Arouses to verbal stimuli but drifts off to sleep.Normal saline infusing in left arm via 18-gauge IV catheter at 250 mL/hr.Urinary catheter draining scant dark amber urine.Pt receiving O₂at 6 L/min via nasal cannula.Lungs with coarse crackles at the left base.Loose cough present.Pt unable to expectorate secretions.-Ann Davids,RN Which type of charting has the nurse used?

Accepted Answer

The nurse has used Narrative charting. This type of charting involves the use of a descriptive narrative to record patient information and care provided. It provides a chronological order of events and captures relevant patient information in a detailed and comprehensive manner.

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, analyze their causes, identify trends and areas for quality improvement, and develop interventions to reduce the risk of future occurrences. They are not strictly required by regulatory agencies or solely used for legal purposes, although they may be used in these contexts.

Question 7

What is the purpose of completing an occurrence report?

Accepted Answer

Completing an occurrence report helps track problems and identify areas for quality improvement, leading to better patient outcomes and preventing future occurrences.

Answer: A
 Completing an occurrence report can provide a legal defense in the event of legal action taken by the patient after an unusual occurrence.

Answer: D
 Completing an occurrence report helps in reporting medical errors to The Joint Commission, which is responsible for accrediting healthcare organizations and ensuring they meet certain standards of quality and safety.

Answer: C
 Completing an occurrence report is not necessary to report errors to the Food and Drug Administration, as there are other reporting mechanisms in place for such situations.

Question 8

The patient's health record contains the following provider's order: furosemide 40 mg intravenously STAT.Where should the nurse look to determine whether the medication was provided and the patient's response?

Accepted Answer

The answer of The patient's health record contains the following...

Question 9

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility?

Accepted Answer

The Minimum Data Set (MDS) must be completed within 14 days after admission for a newly admitted resident of a long-term care facility. This is a requirement to ensure timely and accurate assessment of each resident's needs.

Question 10

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

Accepted Answer

The best choice is to document simply that the patient refused the 0900 dose of medication. It is important to avoid documenting subjective and potentially judgmental language, such as "uncooperative" or "belligerent," unless the behavior is objectively threatening or harmful. Option D is also a correct choice as it documents only the essential information in an objective manner.

Question 11

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1-hour PRN pain.When should the nurse administer the medication?

Accepted Answer

The medication is prescribed as 4 mg intravenously q 1-hour PRN pain. This means that the medication should be given as needed, but not more than once per hour. The nurse should assess the patient's pain level and administer the medication accordingly. Administering the medication every hour around the clock or immediately after taking off the order is incorrect as it does not take into account the patient's pain level. Administering the medication 1 hour after the last dose may be too late if the patient is experiencing significant pain.

Question 12

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?

Accepted Answer

OOB stands for "out of bed." Assisting the patient out of bed in the morning is the action that follows the surgeon's order. Performing oral care, assisting with bathing, or changing operative dressings are not related to the surgeon's OOB order.

Question 13

The nurse receives a telephone verbal order for pain medication for a client: morphine 4 mg intravenously every hour as needed for pain.How should the nurse document this telephone order?

Accepted Answer

The best way to document a telephone order is to include the date and time of the order, the medication name, dose, route, frequency, indication, and the name of the prescriber along with the nurse's name and credentials. Therefore, option B includes all the necessary information required for accurate documentation of a telephone order.

Question 14

A client with respiratory failure is experiencing cyanosis and labored breathing.What action should the nurse take first?

Accepted Answer

The answer of A client with respiratory failure is experiencing...

Question 15

At 1000 on 11/14/17,the nurse receives a telephone order 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

According to the Joint Commission's standards, telephone orders must be countersigned within a time frame specified by the hospital's policy, but no later than 48 hours after the order is given. Therefore, the latest date and time the nurse will expect the prescriber to countersign the order is 11/15/17 at 1000.

Question 16

A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer.How often must the nurse document this patient's care?

Accepted Answer

For a stage 2 pressure ulcer, documentation of care in a long-term care facility should occur every shift to ensure proper monitoring and management of the condition. This frequent documentation helps in assessing the effectiveness of the care plan and making necessary adjustments.

Question 17

The nurse makes a mistake while documenting in the patient's health record.Which action should the nurse take?

Accepted Answer

Drawing a line through the error and initialing the change is the appropriate method of documenting an error in a patient's health record. This ensures that the error is still visible, but it is clear that it has been corrected and who made the correction. Using correction fluid or black ink to cover up the error is often prohibited by hospital policies and can be seen as an attempt to hide the mistake, which can lead to further consequences.

Question 18

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer.Which integrated plan of care (IPOC)would be most appropriate for the nurse to implement?

Accepted Answer

The most appropriate IPOC to implement is for postoperative colon resection, as it directly addresses the patient's current surgical needs and recovery process.

Question 19

A patient is admitted to the emergency department with a stroke.After the patient has been stabilized,which information should the nurse include in the care plan that best meets the patient's needs?

Accepted Answer

The answer of A patient is admitted to the emergency...

Question 20

The nurse receives 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

It is important for the nurse to repeat the order back to the prescriber to ensure accuracy and prevent errors. Even if the nurse believes she understood the order correctly, repeating it back can catch any miscommunications or misunderstandings.

Quiz 18: Documenting Reporting

The department of nursing at a local hospital is considering changing to charting by exception (CBE) .Which statement provides a rationale to support making this change?