Exam 10: Healthcare Team Communication: Documenting and Reporting

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in his or her charting?

Which entry should the nurse include when charting? Select all that apply.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

How can the nurse researcher obtain information from a client record?

What ensures continuity of care?

Which statement describes best practices for charting? Select all that apply.

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which information should the nurse record in his or her charting? Select all that apply.

Which characteristic of a nurse's charting will assist most in the avoidance of errors?

Charting in which the nurse writes a progress note that relates to one health problem is a:

How can a nurse obtain additional information about a client?

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining:

Which organization audits charts regularly?

A nurse is working as a case manager, and in this role, he or she audits charts. Audits of client records are performed primarily for quality assurance and:

Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss?

During a client's hospitalization, the client has developed shortness of breath, with edema. What action should the nurse take?

What dual purpose does an audit serve?

The nurse is caring for a client with uncontrolled hypertension. His or her blood pressure has remained controlled for the nurse's shift. At 2-hour intervals, the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the client has a stroke. Years later, the client files a lawsuit blaming the hospital for the stroke. The nurse who was caring for the client when the client's blood pressure was stable cannot recall the exact blood pressure readings obtained, but remembers it was normal. Will this recollection suffice in court and why?

The federally initiated goal of computer-based personal records would likely produce which of the following benefits? Select all that apply.

The client record is utilized for many purposes. Which might be a use for the client record? Select all that apply.

A new graduate is working at the graduate's first job. Which statement is most important for the new nurse to follow?