Deck 37: Documenting and Reporting

Question 1

Which intervention should the nurse implement to facilitate continuity of care?

A) Ensure that the client interacts with the other caregivers.
B) Ensure that other care providers are assigned night shifts.
C) Ensure that the client's family interacts with other caregivers.
D) Ensure documentation of the client's appearance, behavior, and responses.

Answer 1

Ensure documentation of the client's appearance, behavior, and responses.

Question 2

A nurse is caring for a client who is having an extended recovery period. Which intervention would be most effective in improving care for this client?

A) Review the client's health record.
B) Closely monitor the client's vital signs.
C) Interact more frequently with the client.
D) Identify simpler goals for the client.

Answer 2

Review the client's health record.

Question 3

Which is the primary goal for maintaining a healthcare record for the client in particular?

A) Meeting established legal requirements
B) Documenting the ongoing health status of the client
C) Verifying data for quality assurance program evaluations
D) Providing information to be used as a resource for educational purposes

Answer 3

Documenting the ongoing health status of the client

Question 4

What client focused information should the nurse document in the client's manual health record?

A) Long-term goals
B) Vital signs
C) Short-term goals
D) Weekly progress status

Question 5

Which nursing interventions are helpful when considering the facility's need to be financially accountable? Select all that apply.

A) Provide safe and effective healthcare to all clients.
B) Ensure that the facility meets the governmental standards of care.
C) Document all the treatments given to each client
D) Verify the use of special equipment required to provide safe client care
E) Record all billable services in the appropriate health records.

Question 6

A nurse is caring for a client in a healthcare facility who is about to be transferred to another healthcare facility for specialized care. Which data would be most helpful to ensure continuity of care?

A) Transfer notes summarizing care.
B) Referrals to community health services.
C) Short-term goals to be achieved.
D) Referrals to telephone consultation services.

Question 7

Which document would be most helpful in determining the client's ability to perform activities of daily living?

A) Medical information systems (MIS)
B) Medical administration record (MAR)
C) Resident assessment protocol (RAP)
D) Charting by exception (CBE)

Question 8

Which statement describes the purpose of progress records?

A) Records all client information
B) Guides nurses in the development of individualized care plans
C) Provides access to the healthcare provider's orders and the nursing care plan
D) Describes the treatment and responses of the client

Question 9

Which type of note does the nurse enter into the medical record at regular intervals to summarize the client's condition or response to treatment?

A) SOAP
B) Charting by exception
C) Progress
D) DARE

Question 10

Which data entry systems are examples of focus charting? Select all that apply.

A) SOAP
B) APIE
C) PIE
D) DARE
E) SOAPIER

Question 11

Which statement describes the best technique for identifying that a written error was made in a manual record sheet?

A) Erase the incorrect statement and write the correct one.
B) Cross out the incorrect statement with a single line.
C) Cross out the wrong statement in a way that is not readable.
D) Use correction ink to mark the wrong statement.

Question 12

During a change of shift reporting, a nurse has to substitute for the nurse who was primarily responsible for the care of a client. Which process would be most effective for the nurse's change-of-shift reporting?

A) Use the clinical care path as the guide.
B) Record any failure in achieving short-term goals.
C) Prepare a written summary for the oncoming nurse.
D) Report on specific nursing diagnosis.

Question 13

The nurse has to document information to maintain the health record of the client. Which nursing action is required for each charting entry?

A) Reporting each observation to the healthcare provider.
B) Signing the record with first initial, last name, and classification.
C) Obtaining a signature from the primary care provider.
D) Providing the day of the week on the entry.

Question 14

Which statement accurately describes aspects of computerized charting?

A) The system is relatively inexpensive to maintain.
B) Bedside terminals eliminate the use of flow sheets and manual notes.
C) The system provides speed and convenience for both entering and retrieving information.
D) The system better protects client privacy than does conventional charting and storage methods.

Question 15

The nurse is reviewing a chart updated using the charting by exception format. Where would the nurse find the client's most recent lung sounds?

A) Narrative notes
B) Discipline area notes
C) Flow sheets
D) Problem-oriented list

Question 16

When considering documentation, what information should the nurse include on the client's MAR?

A) Lists all the medications that the primary care provider has ordered for the client with spaces for the caregiver to mark when medications are given.
B) Documents large amount of information collected at intervals over a specified period of time in brief, concise entries.
C) At regular intervals, a summary of the client's condition or response to treatment is made.
D) Summarizes an account of a client's relationship with a healthcare facility.

Question 17

What key guidelines are generally accepted for documentation of nursing care? Select all that apply.

A) Document what should be done.
B) Documentation should be specific.
C) Use direct quotes in documentation whenever possible.
D) Documentation should be completed promptly.
E) Document what you see.

Question 18

Which statement entered into the medical record by the nurse is both objective and descriptive while demonstrating the principles of documentation?

A) Client lonely
B) Client out of touch with reality
C) Client in pain
D) Client rocking in chair

Question 19

Which is the correct abbreviation for before meals?

A) AC
B) BM
C) IM
D) PC

Question 20

Why were apothecary units placed on the "do not use" list? Select all that apply.

A) Misinterpreted because of similar abbreviations for multiple medications
B) Unfamiliar to many practitioners
C) Easily confused with metric units
D) Commonly mistaken for the number two
E) They are difficult to print

Question 21

Why was U placed on the "do not use" list? Select all that apply.

A) Mistaken for zero
B) Mistaken for the number 4
C) Mistaken for cubic centimeters
D) Mistaken for the number 10
E) Mistaken for Unit

Question 22

What is the meaning of the abbreviation "Ungt"?

A) It is not an acceptable abbreviation
B) Under the groin
C) Ointment
D) Undergarment