Deck 15: Documenting and Reporting

Question 1

The charge nurse is evaluating patient documentation of a new staff nurse.Based on which of the following does the charge nurse note,on review of the new nurse's charting,that appropriate documentation is evident?

A) A pencil was used to make the entries.
B) Correction fluid was used to correct written errors.
C) An error made by the attending physician was documented.
D) All of the entries he or she made in the record were dated and signed.

Answer 1

D

Question 2

To avoid legal risks and possible lack of confidentiality associated with computerized documentation,which of the following statements is true of many current software programs?

A) All nursing staff use the same access code.
B) Only centralized medical records use the patient data.
C) Thumbprint identification restrictions are in place.
D) Staff password changes are periodically required.

Answer 2

D

Question 3

The nurse is documenting on the patient's record and notes that he or she has made an error.What action should the nurse take?

A) Draw a line through the error, and initial and date it.
B) Erase the error, and write over the material in the same spot.
C) Use a dark-coloured marker to cover the error, and continue immediately after that point.
D) Footnote the error at the bottom of the page, including initials and the date.

Answer 3

A

Question 4

Which of the following is evaluated as a legally appropriate notation?

A) "Dr. Green made an error in the amount of medication to administer."
B) "Patient verbalized sharp, stabbing pain along the left side of chest."
C) "Nurse Williams spoke with the patient about the surgery."
D) "Patient upset about the physiotherapy."

Question 5

Which of the following types of documentation is represented by the statement,"Patient is wheezing and experiencing some dyspnea on exertion"?

A) The "S" in SOAP documentation
B) Focus documentation
C) The "P" of PIE documentation
D) The "R" in DAR documentation

Question 6

Which of the following is true about a flow sheet?

A) Information is outdated.
B) The quantity of narrative notes is increased.
C) There is an increased chance of errors from transfer of information.
D) Team members can quickly identify trends over time of care.

Question 7

When documenting care that has been implemented by the nurse,what is the term used to describe an older adult who is living in a long-term care or residential facility?

A) Client
B) Patient
C) Resident
D) Individual

Question 8

Which of the following is true in regard to a source record?

A) Interprofessional documentation is involved.
B) Content is organized by discipline.
C) It documents deviations from the norm.
D) It documents the source of the patient problem.

Question 9

Which of the following terms describes an unexpected occurrence when the unit documentation is a critical pathway?

A) Incident
B) Variance
C) Deviation
D) Charting by exception

Question 10

Guidelines should be followed when documenting patient care.Which one of the following does the nurse recognize as the most appropriate notation?

A) "1230 hours: Patient's vital signs taken"
B) "0700 hours: Patient drank adequate amount of fluids"
C) "0900 hours: Morphine given for lower abdominal pain"
D) "0830 hours: Increased IV fluid rate to 100 mL per hour"

Question 11

What does the final "R" represent when using the I-SBAR-R communication technique?

A) Recovery
B) Repeat back
C) Reorganization
D) Reintegration

Question 12

A slight hematoma has developed on the patient's left forearm.The nurse labels the problem as an infiltrated intravenous (IV)line.The nurse elevates the forearm.The patient states,"My arm feels better." Which of these is documented as the "R" in the data-action-response (DAR)notes of focus charting?

A) "My arm feels better."
B) "Slight hematoma on left forearm"
C) "Infiltrated IV line"
D) "Elevation of left forearm"

Question 13

Where does the nurse record a description of the teaching provided to the patient on performance of self-medication administration?

A) Kardex form
B) Incident report
C) Nursing history form
D) Discharge summary form

Question 14

The nurse is preparing the information that will be provided to the staff on the next shift.Which of the following should the nurse include in the change-of-shift report to nursing colleagues?

A) A description of the steps of procedures done
B) A review of routine care for the patient
C) All routine care procedures required by the patient
D) Essential background information about the patient

Question 15

It is late at night on the medical unit in the hospital,and the physician calls to leave orders for one of his patients.The licensed practical nurse answers the phone and appropriately responds with which of the following statements?

A) "Let me get the registered nurse on the phone."
B) "I am unable to take the order at this time. Please call in the morning."
C) "Please repeat the order for me, so that I can make sure it is written correctly."
D) "Let me have your phone number, and I will have the supervisor call you back."