Exam 18: Documenting Reporting

The nursing instructor is teaching the student about occurrence reports.Which statement by the student indicates an understanding of the purpose of occurrence reports?

What is one advantage of problem-intervention-evaluation (PIE)charting?

The instructor is teaching the nursing students about electronic health records (EHR).Which student statement indicates the need for further instruction?

The electronic health record (EHR)is used to document client care management.Which statement(s)below is/are applicable to EHR? Select all that apply.

A client is admitted to the birthing unit to rule out preterm labor.The nurse charts only abnormal findings.This type of charting is a form of:

The nurse notifies the primary care provider that the patient is experiencing pain.The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain.How should the nurse document this telephone order?

The nurse takes 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?

Why might a healthcare provider choose narrative charting instead of using forms or checklists?

At the end of a 12-hour shift,the nurse gives a verbal report to the oncoming nurse.This face-to-face reporting,using the acronym "CUBAN," does which of the following?

A resident in a long-term care facility is unable to provide self-care owing to dementia and is receiving Medicare funds.How often must the nurse document this resident's care?

A client is admitted to a long-term care facility.The nurse knows that federal law requires the use of:

In performing a handoff report,the nurse should communicate information on which of the following? Select all that apply.

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure.The client's condition is getting worse; he is cyanotic (turning blue)with periods of labored breathing.What action should the nurse take first?

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? The nurse:

Knowing that discharge summary information is integral to the client's ongoing care,which of the point(s)regarding discharge summaries must the nurse be aware? Select all that apply.

The nurse is administering the 0900 dose of heparin 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT).At 0800,the patient's laboratory values show partial thromboplastin time (PTT)and clotting times are four times the normal range.The nurse observes petechiae on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding.The correct nursing actions at this time are below.Select all that apply.

Which statement(s)by the student nurse indicates an understanding of the nursing Kardex? Select all that apply.

A student nurse makes the following comments to her preceptor: "I love getting information from the chart.Everything related to the patient's problem is together and addressed by various members of the healthcare team." The student nurse has been introduced to which type of charting system?

Which instruction by a registered nurse should the student nurse clarify with her clinical instructor? "When taking off the provider's orders,you should:

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