Exam 15: Documenting and Reporting

The nurse is preparing the information that will be provided to the staff on the next shift.Which of the following should the nurse include in the change-of-shift report to nursing colleagues?

Which of the following is true about a flow sheet?

It is late at night on the medical unit in the hospital,and the physician calls to leave orders for one of his patients.The licensed practical nurse answers the phone and appropriately responds with which of the following statements?

When documenting care that has been implemented by the nurse,what is the term used to describe an older adult who is living in a long-term care or residential facility?

Where does the nurse record a description of the teaching provided to the patient on performance of self-medication administration?

The nurse is documenting on the patient's record and notes that he or she has made an error.What action should the nurse take?

The charge nurse is evaluating patient documentation of a new staff nurse.Based on which of the following does the charge nurse note,on review of the new nurse's charting,that appropriate documentation is evident?

Guidelines should be followed when documenting patient care.Which one of the following does the nurse recognize as the most appropriate notation?

Which of the following terms describes an unexpected occurrence when the unit documentation is a critical pathway?

Which of the following is true in regard to a source record?

To avoid legal risks and possible lack of confidentiality associated with computerized documentation,which of the following statements is true of many current software programs?

Which of the following types of documentation is represented by the statement,"Patient is wheezing and experiencing some dyspnea on exertion"?

What does the final "R" represent when using the I-SBAR-R communication technique?

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." Which of these is documented as the "R" in the data-action-response (DAR)notes of focus charting?

Which of the following is evaluated as a legally appropriate notation?