Exam 15: Documenting and Reporting

A nurse has taught the patient how to use crutches.The patient went up and down the stairs using crutches with no difficulties.Which information will the nurse use for the "I" in PIE charting?

A patient is being discharged home.Which information should the nurse include?

Which entry will require follow-up by the nurse manager?

A nurse is using the source record and wants to find the patient's daily weights.Where should the nurse look?

According to documentation guidelines the most appropriate notation is

Which situation will require the nurse to obtain a telephone order?

A nurse is a member of an interdisciplinary team that uses critical pathways.According to the critical pathway,on day 2 of the hospital stay,the patient should be sitting in the chair.It is day 3,and the patient cannot sit in the chair.What should the nurse do?

A nurse preceptor is supervising a student nurse.Which behaviour by the student nurse will require the nurse preceptor to intervene?

A nurse is giving a hand-off report to the nurse on the next shift.Which information is critical for the nurse to report?

The final "R" when using the I-SBAR-R communication technique represents which of the following?

A nurse is charting on a patient's record.Which action is most accurate legally?

A new nurse asks the preceptor why a change-of-shift report is important,inasmuch as care is documented in the chart.What is the preceptor's best response?

A nurse wants to reduce data entry errors on the computer system.Which behaviour should the nurse implement?

A nurse is discussing the advantages of standardized documentation forms in the nursing information system.Which advantage should the nurse describe?

A nurse prepared an audiotaped exchange with another nurse of information about a patient.Which action did the nurse complete?

A nurse wants to integrate all pertinent patient information into one record,regardless of the number of times a patient enters the health care system.Which term should the nurse use to describe this system?

A preceptor is supervising a new nurse on documentation.Which situation will cause the preceptor to intervene?

The action that a nurse would take when documenting on the patient's record and notes that he or she has made an error is which of the following?

A slight hematoma has developed on the patient's left forearm.The nurse labels the problem as an infiltrated intravenous (IV)line.The nurse elevates the forearm.The patient states,"My arm feels better." When using the DAR notes of focus charting,the nurse would document the "R" as which of the following?

A nurse obtained a telephone order (TO)from a primary care provider for a patient in pain.Which chart entry should the nurse document?