Deck 24: Documenting and Reporting

Question 1

While discussing confidentiality policies and laws protecting client records,a student asks why it is acceptable for them to have access to client records in the clinical area.What is the correct rationale for this?

A)Confidentiality and privacy laws don't apply to students.
B)Students could not possibly remember details from all of the charts that they read.
C)Client records are used for learning purposes,but the student is bound to hold all information in strict confidence.
D)If the clinical instructor is in the area,accessing client records is part of the education process.

Answer 1

Client records are used for learning purposes,but the student is bound to hold all information in strict confidence.

Question 2

Documentation arranged in a chronological order,from the time the nurse started the shift until the nurse entered the documentation in the client's record,is an example of which of the following?

A)Problem-oriented recording
B)Source-oriented recording
C)Narrative charting
D)Plan of care

Answer 2

Narrative charting

Question 3

A client did not meet the goal of walking independently,without assistive devices,by discharge.The case manager,using a critical pathway,would identify this as which of the following?

A)An unattainable goal
B)A variance
C)An incorrectly written care plan
D)An error in judgment on the case manager's part

Answer 3

A variance

Question 4

A cardiac specialty hospital has several written plans in place according to specific medical diagnoses.Typical nursing diagnoses as well as standard nursing interventions are included in these plans.This hospital is utilizing which of the following?

A)Standardized care plans
B)Traditional care plans
C)Critical pathways
D)Kardex

Question 5

Liam,19,is brought to the emergency department by police.There are numerous large areas of bruising around his throat and upper arms,his upper lip is cut,and his clothes are ripped.What is the most appropriate documentation for this situation?

A)Client brought to the ED,victim of some type of abuse,in police custody.
B)Client had areas of bruising on throat and upper arms-as if someone had choked him-clothing ripped.
C)Client brought to ED by police.Bruising to throat and upper arms,measuring 15 to 20 cm.Clothes ripped.
D)Police brought client to the ED after getting assaulted.Clothes ripped,bruising to throat and upper arms noted.Lip cut.

Question 6

A nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording.When searching for the most recent physician's orders,the nurse should look in which section?

A)Database
B)Problem list
C)Plan of care
D)Progress notes

Question 7

Nursing students must thoroughly research information about their assigned clients in order to provide appropriate and safe care during their clinical experiences.In order to help students save time in researching all of this information,what should be their first place to start the review?

A)Medical record
B)Medication administration record (MAR)
C)Written care plan
D)Kardex

Question 8

Which of the following statements best describes focus charting?

A)Information is limited to physiological problems.
B)It eliminates repetitive charting by documenting only exceptions to norms.
C)Focus charting minimizes the use of flowsheets.
D)It organizes progress notes by data,action,and response.

Question 9

Which of the following types of information would be most informative and should be given in the change-of-shift report?

A)Vital signs: BP 120/80,pulse 72,respirations 16
B)Client is alert and in good spirits.
C)Chest X-ray taken two days ago was negative.
D)Voided 400 mL yellow urine 4 hours after catheter removal

Question 10

Under which category of SOAP charting would the nurse look to determine whether or not a client had reported having nausea?

A)Subjective data
B)Objective data
C)Assessment
D)Plan

Question 11

Michalea,a nursing student,discovers that she has written in the wrong chart.What is the correct action to take?

A)Use correction fluid over the error
B)Blacken out all the documentation
C)Strike an "X" through the entire page,mark "error," and initial
D)Draw a line through the entry,write "mistaken entry," and initial

Question 12

The nurse responds to a client's call light.When entering the room,the nurse sees that the client is lying on the floor,with the bed linens around his legs.Which of the following would be the most correctly written chart entry?

A)Recorder found client on floor; seems to have fallen out of bed by getting tangled in bed linens
B)Client became tangled in the bed linens,then called for assistance after falling out of bed
C)Recorder responded to client's call light; upon entering the room,found client on floor
D)Client fell out of bed,but did push the call button for assistance

Question 13

The client states,"I do not want anyone to visit me who has not been cleared through me first." If utilizing the SOAP format,this statement would be documented under which category?

A)Subjective data
B)Planning
C)Assessment
D)Objective data

Question 14

A nurse administers analgesic medications to a client through a central line.This information should be documented in which section if using PIE charting?

A)Problem statement
B)Intervention
C)Evaluation
D)Progress notes

Question 15

Mr.Suzuki,79,is deteriorating but remains alert and oriented.Three days after admission,he tells his nurse,"I am tired of being sick.I wish I could end it all." What is the most accurate and informative way to record this data in the progress notes?

A)Appears to be depressed,possibly suicidal
B)Complains he is tired of being ill and wants to die
C)Does not want to live any longer because he is tired of being ill
D)Client states,"I am tired of being sick.I wish I could end it all."

Question 16

A nurse charts,"NG tube irrigated with 25 mL of normal saline." For the focus charting method,which category would be appropriate for this entry?

A)Data
B)Action
C)Response
D)Plan

Question 17

A nurse returns to work following a vacation and is assigned to new clients.Where can the nurse quickly find accurate,up-to-date information on each client?

A)Kardex
B)Previous nurse's worksheet
C)Admission sheet of each client
D)Computer printout of hospital census

Question 18

A client has specific cultural needs in regards to the plan of care.This information would be found in which of the following?

A)Database
B)Problem list
C)Plan of care
D)Progress notes

Question 19

The client,after receiving emergency treatment for an acute asthma attack,had diminished wheezing in both lungs.When utilizing focus charting,this information would be included in which section?

A)Response
B)Action
C)Data
D)Plan

Question 20

At the end of the shift,the nurse is reviewing client documentation.Among the chart entries,special attention is paid to the flow sheets and abnormal assessment findings for each client.This type of charting is an example of which of the following?

A)Computerized documentation
B)Focus charting
C)SOAP charting
D)Charting by exception

Question 21

Which of the following is a type of flowsheet?

A)Medication administration record
B)Progress notes
C)Discharge summary
D)Kardex

Question 22

Which of the following is a guideline for documentation in the home-care setting?

A)Document and report any change in the client's condition to the physician and the client's family within 24 hours
B)Write a discharge summary,including the client's health status at discharge,outcomes achieved,and recommendations for further care
C)Keep a record of client's activities of daily living
D)Keep a record of any visits and phone calls from family,friends,and others regarding the client

Question 23

The nurse charts the following: "stated that he had vomited 250 mL yellow-green emesis." This entry goes under which section of the focus charting method?

A)Data
B)Action
C)Response
D)Objective

Question 24

What does SBAR mean?

A)SBAR is an abbreviation for a commonly-ordered liver function test.
B)It is a framework used for narrative charting.
C)SBAR is a system used for filling out incident reports.
D)It is a communication tool for change-of-shift.

Question 25

A physician writes the abbreviated order,DAT.What does it mean?

A)Discharge assessment today
B)Do not ambulate today
C)Diet as tolerated
D)Daily activity as tolerated

Question 26

Which of the following is a charting ERROR?

A)Using a black ballpoint pen to document
B)Hand printing nurses' notes because one's cursive writing is hard to read
C)Signing nurses' note that the relief nurse wrote earlier in the shift
D)Including the date and time in each chart entry

Question 27

A physician has called with a telephone order for one of her clients.What is the appropriate action by the registered nurse?

A)Write the order in the chart,and have the charge nurse co-sign it
B)Copy the order onto the order sheet,then repeat the order back to the physician,indicating "TO" for telephone order
C)Explain to the physician that a staff nurse cannot take the order but that the nurse will page the nursing supervisor
D)Copy the order onto the physician's order sheet,and sign the physician's name,copying her handwriting as closely as possible