Question 1

Charting by exception (CBE)is best described as a system of charting that

Accepted Answer

A) Does not encompass the use nursing diagnosis. 
B) Necessitates a complete nursing assessment at the beginning and end of each shift. 
C) Requires a data entry every 2 hours in the nursing notes. 
D) Only addresses client changes when the predetermined norm is not met. 
A) Does not encompass the use nursing diagnosis. 
B) Necessitates a complete nursing assessment at the beginning and end of each shift. 
C) Requires a data entry every 2 hours in the nursing notes. 
D) Only addresses client changes when the predetermined norm is not met. D

Question 2

Client care plans are used in client care for which of the following reasons? Choose one answer.

Accepted Answer

A) To describe specific medication orders that are to be followed. 
B) To determine client status. 
C) To document laboratory values and specific diagnostic tests. 
D) To provide a source of communication between nurses on various shifts. 
A) To describe specific medication orders that are to be followed. 
B) To determine client status. 
C) To document laboratory values and specific diagnostic tests. 
D) To provide a source of communication between nurses on various shifts. D

Question 3

Unusual occurrences serve the purpose of documenting quality of care,identifying areas where in-service education is needed,and recording the details of the incident for legal documentation.

Accepted Answer

A) True 
 B)False  True

Question 4

Which one of the following statements is true regarding CNAs abd UAPs charting.

Accepted Answer

A) They can not chart except on a vital signs clipboard at the nurses' station. 
B) They can chart hygienic care when flow sheet charting is used. 
C) They can document hygienic care on nurses' notes when narrative charting is used. 
D) They cannot chart any information on any charting system. 
A) They can not chart except on a vital signs clipboard at the nurses' station. 
B) They can chart hygienic care when flow sheet charting is used. 
C) They can document hygienic care on nurses' notes when narrative charting is used. 
D) They cannot chart any information on any charting system.

Question 5

When activating a care plan,the most appropriate method is to

Accepted Answer

A) Place a care plan in the chart. 
B) Draw a line through the interventions that are not relevant. 
C) Sign the care plan in the appropriate section. 
D) Circle and date the relevant problems and nursing interventions. 
A) Place a care plan in the chart. 
B) Draw a line through the interventions that are not relevant. 
C) Sign the care plan in the appropriate section. 
D) Circle and date the relevant problems and nursing interventions.

Question 6

When a client does not achieve the expected outcomes listed on the clinical path,in a specific time frame,what consequences occur?

Accepted Answer

A) Hospitals must obtain permission to continue to treat the client. 
B) An individualized care plan is initialed for the "variance." 
C) All documentation must now be completed on the individualized care plan. 
D) Documentation continues on the individualized care plan until the client is discharged. 
A) Hospitals must obtain permission to continue to treat the client. 
B) An individualized care plan is initialed for the "variance." 
C) All documentation must now be completed on the individualized care plan. 
D) Documentation continues on the individualized care plan until the client is discharged.

Question 7

Match between columns
                        Premises: Computer entries are not deleted even when they are no longer relevant to client care.
The nurse must be extremely careful when entering data into the computer,as it is very easy to delete information.
The password you use to enter the computer cannot be given to a physician to assist him or her with data entry.
It is important that records have backup files as a safety factor.

Accepted Answer

The Answer of True and False is...

Question 8

Which one of the following statements regarding clinical paths is correct?

Accepted Answer

A) This is a format for documenting nursing tasks and eliminates the need for other flow sheets,graphic forms,etc. 
B) Discharge planning is initiated after the first "variance" occurs. 
C) Use of critical paths reduce client complication rates and hospital costs. 
D) All clients should be placed on a clinical path at the time of admission. 
A) This is a format for documenting nursing tasks and eliminates the need for other flow sheets,graphic forms,etc. 
B) Discharge planning is initiated after the first "variance" occurs. 
C) Use of critical paths reduce client complication rates and hospital costs. 
D) All clients should be placed on a clinical path at the time of admission.

Question 9

State three examples of "Rights of Delegation" state boards of nursing have identified.

Accepted Answer

Examples of "Rights of Delegat

Question 10

Charting is one of the nurse's most important functions.Which of the following is the most important purpose of charting?

Accepted Answer

A) To communicate to other members of the client's health care team. 
B) To evaluate the staff's performance. 
C) To provide information for a nursing audit. 
D) To enable physicians to monitor nursing care. 
A) To communicate to other members of the client's health care team. 
B) To evaluate the staff's performance. 
C) To provide information for a nursing audit. 
D) To enable physicians to monitor nursing care.

Question 11

A major advantage of a computer-based documentation system is

Accepted Answer

A) All health care staff can chart in the nursing notes. 
B) The system provides reference material for common nursing problems. 
C) Nurses do not need to check the physician's orders as they are transferred to the appropriate department for implementation. 
D) Information is readily available with minimal delays. 
A) All health care staff can chart in the nursing notes. 
B) The system provides reference material for common nursing problems. 
C) Nurses do not need to check the physician's orders as they are transferred to the appropriate department for implementation. 
D) Information is readily available with minimal delays.

Question 12

It is important to record any unscheduled or prn medication.The following is an accurate representation of this type of charting.
"8 p.m.c/o abdominal incisional pain after ambulation.Depo Dur 10 mg IM for pain."

Accepted Answer

A) True 
 B)False

Question 13

The team leader RN can delegate all of the following client activities to other health care workers except

Accepted Answer

A) Admission vital signs. 
B) Wound dressing change. 
C) Reviewing a teaching activity with the client. 
D) .Establishing long-term client goals. 
A) Admission vital signs. 
B) Wound dressing change. 
C) Reviewing a teaching activity with the client. 
D) .Establishing long-term client goals.

Question 14

Nursing care plans should be updated at least

Accepted Answer

A) Prior to discharge. 
B) When a new nurse is assigned to the client. 
C) Every 24 to 48 hours. 
D) Each time a new problem arises. 
A) Prior to discharge. 
B) When a new nurse is assigned to the client. 
C) Every 24 to 48 hours. 
D) Each time a new problem arises.

Question 15

Clinical Situation: You have just completed an admission assessment on the following client, and based on the collected data, you begin the client care plan.
The client is a 39-year-old single male admitted for upper right-quadrant pain following a week-long episode of flu-like symptoms. He has not eaten for 7 days and presents with signs and symptoms of dehydration and malnutrition. He has not been out of bed during the week. He lives alone and states he either buys frozen foods or eats in fast-food restaurants.
. (When filling in the content in the care plan, remember that the material is not necessarily related. This exercise is designed to determine your care plan knowledge base, not your medical knowledge. Use the care plan found later in the text for documenting data.)
-Which one of the following client problems is related to the client's condition? Circle the correct letter,and write the selected problem in the appropriate section of the care plan.

Accepted Answer

A) Fluid volume excess. 
B) Fear. 
C) Sensory perceptual alterations (kinesthetic). 
D) Impaired skin integrity. 
A) Fluid volume excess. 
B) Fear. 
C) Sensory perceptual alterations (kinesthetic). 
D) Impaired skin integrity.

Question 16

Critical or clinical paths are used primarily in the following health care setting

Accepted Answer

A) Short-term admission facilities. 
B) Out-patient facilities. 
C) Recovery or post anesthesia rooms. 
D) Managed care delivery settings. 
A) Short-term admission facilities. 
B) Out-patient facilities. 
C) Recovery or post anesthesia rooms. 
D) Managed care delivery settings.

Question 17

Clinical Situation: You have just completed an admission assessment on the following client, and based on the collected data, you begin the client care plan.
The client is a 39-year-old single male admitted for upper right-quadrant pain following a week-long episode of flu-like symptoms. He has not eaten for 7 days and presents with signs and symptoms of dehydration and malnutrition. He has not been out of bed during the week. He lives alone and states he either buys frozen foods or eats in fast-food restaurants.
. (When filling in the content in the care plan, remember that the material is not necessarily related. This exercise is designed to determine your care plan knowledge base, not your medical knowledge. Use the care plan found later in the text for documenting data.)
-The fact that the client lives alone should be documented in which section of the care plan?

Accepted Answer

Relevant i

Exam 3: Managing Client Care: Documentation and Delegation

Charting by exception (CBE)is best described as a system of charting that

Client care plans are used in client care for which of the following reasons? Choose one answer.

Unusual occurrences serve the purpose of documenting quality of care,identifying areas where in-service education is needed,and recording the details of the incident for legal documentation.

Which one of the following statements is true regarding CNAs abd UAPs charting.

When activating a care plan,the most appropriate method is to

When a client does not achieve the expected outcomes listed on the clinical path,in a specific time frame,what consequences occur?

Which one of the following statements regarding clinical paths is correct?

State three examples of "Rights of Delegation" state boards of nursing have identified.

Charting is one of the nurse's most important functions.Which of the following is the most important purpose of charting?

A major advantage of a computer-based documentation system is

It is important to record any unscheduled or prn medication.The following is an accurate representation of this type of charting. "8 p.m.c/o abdominal incisional pain after ambulation.Depo Dur 10 mg IM for pain."

The team leader RN can delegate all of the following client activities to other health care workers except

Nursing care plans should be updated at least

Critical or clinical paths are used primarily in the following health care setting

Professional Nursing

Nursing Process and Critical Thinking

Communication and Nurse-Client Relationship

Admission, Transfer, and Discharge

Client Education and Discharge Planning

Safe Client Environment and Restraints

Bathing, Bedmaking, and Maintaining Skin Integrity

Personal Hygiene

Vital Signs

Physical Assessment

Body Mechanics and Positioning

Exercise and Ambulation

Infection Control

Disaster Preparedness Bioterrorism

Pain Management

Alternative Therapies and Stress Management

Medication Administration

Nutritional Management and Ng Intubation

Specimen Collection

Diagnostic Procedures

Urinary Elimination

Bowel Elimination

Heat and Cold Therapies

Wound Care and Dressings

Perioperative Care

Orthopedic Interventions

Intravenous Therapy

Central Vascular Access

Respiratory Care

Circulatory Maintenance

Neurological Management - New

Advanced Nursing Skills

End of Life Care

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