Exam 16: Documenting, Reporting, Conferring, and Using Informatics

A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality?

A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called?

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation?

A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports?

What activity in charting will assist most in the avoidance of errors?

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document?

What is the primary purpose of an incident report?

A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing?

Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that apply.

A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse?

In what type of documentation method would a nurse document narrative notes in a nursing section?

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?

A nurse is documenting the intensity of a client's pain. What would be the most accurate entry?

A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent?

A physician's order reads "up ad lib." What does this mean in terms of client activity?

Which of the following data entries follows the recommended guidelines for documenting data?

A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation?

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider?

In which of the following cases should a progress note be written? Select all that apply.