Exam 24: Documenting and Reporting

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?

The nurse charts the following: "stated that he had vomited 250 mL yellow-green emesis." This entry goes under which section of the focus charting method?

Which of the following statements best describes focus charting?

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

Which of the following is a guideline for documentation in the home-care setting?

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?

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

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?

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?

Which of the following is a type of flowsheet?

What does SBAR mean?

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

A physician writes the abbreviated order,DAT.What does it mean?

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?

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?

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?

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?

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

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?

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?