Deck 15: Documenting and Reporting

Question 1

The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording.In which section would the nurse find the most recent physician orders?

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

Answer 1

Plan of care

Question 2

The nurse working in a hospital that utilizes a charting by exception (CBE)documentation system notes that a client did not require care in all of the areas identified on a flow sheet.What action should the nurse take?

A)Leave the areas blank.
B)Leave the areas blank,but then add an extensive explanation in the progress notes section of the chart.
C)Write N/A on the flow sheet in the areas that are not applicable to that client.
D)Make sure this information gets passed along in the shift report.

Answer 2

Write N/A on the flow sheet in the areas that are not applicable to that client.

Question 3

Before providing care,the nurse reviews the client's pertinent history,daily treatments,diagnostic procedures,allergies,problems,and other information.Which form should the nurse review to learn all of this information?

A)The client's medical record
B)The MAR (medication administration record)
C)The written care plan
D)The Kardex

Answer 3

The Kardex

Question 4

After classroom discussion regarding confidentiality policies and laws protecting client records,a student asks why it's permissible for them to review and have access to client records in the clinical area.How should the nursing instructor respond?

A)"Confidentiality and privacy laws don't apply to students."
B)"Most students review so many records and charts that they could not possibly remember details from any one of them."
C)"Records are used in educational settings and for learning purposes,but the student is bound to hold all information in strict confidence."
D)"As long as the clinical instructor is in the area,accessing client records is part of the education process."

Question 5

A hospital is not able to be reimbursed for care a particular client received while in the emergency department.The client came in with chest pain,which was later diagnosed as gastric reflux.Which problem with documentation might have caused the lack of reimbursement?

A)The client's record contained an incorrect DRG.
B)The client was charged for an ECG.
C)A code cart was opened and the client was charged for medications opened but not used.
D)The physician made a diagnostic mistake.

Question 6

The nurse works at an organization that is installing a new computerized record system.What should the nurse learn that has been implemented to help ensure the security of client records?

A)A firewall to protect the server from unauthorized access
B)One unit password to protect the unit's information
C)Expectation to log off a terminal after using it
D)Expectation to turn the monitor away from view when unattended
E)Requirement to shred all computer-generated worksheets

Question 7

When attempting to locate recent lab results,the new nurse employee notices that each department has a separate section in the client's chart.Which type of documentation system is the nurse using?

A)Source-oriented record
B)Problem-oriented record
C)Case management
D)Focus charting

Question 8

The nurse administered analgesic medications to an assigned client via central line.In which section of PIE charting should the nurse document this information?

A)Plan
B)Intervention
C)Evaluation
D)Progress notes

Question 9

The nurse makes chronological entries in a client's chart that include documentation about the routine care provided,assessment findings,and client problems during a 12-hour shift.Which type of charting is this nurse completing?

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

Question 10

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

A)Data (D)
B)Action (A)
C)Response (R)
D)Planning (P)

Question 11

A client in long-term care is scheduled for a review of the assessment and care screening process.Where should the nurse document this information?

A)MDS
B)OBRA
C)CBE
D)Kardex

Question 12

A client has specific cultural needs that affect the plan of care.In which part of the client's problem-oriented medical record should the nurse document this information?

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

Question 13

The nurse is documenting client care on flow sheets that identify abnormal assessment findings.Which type of documentation system is the nurse using?

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

Question 14

A client did not meet the goal of walking unassisted,without assistive devices,by discharge from rehabilitation.The case manager using a critical pathway should identify this outcome as being which of the following?

A)An unattainable goal
B)A variance
C)An error in care planning
D)An error in intervention implementation

Question 15

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him,as it's his record.How should the nurse respond to this client's request?

A)"You'll have to ask your doctor for permission to do that."
B)"Actually,the original record is the property of the hospital,but you are welcome to copies of your records."
C)"We'll make sure that all of your records are sent ahead to the rehab hospital,so you don't really have to worry about those details."
D)"There's a new law that protects your records,so you're not going to be able to have access to them."

Question 16

After completing the client care and documenting it in the progress notes,the nurse realizes that documentation was placed on the wrong medical record.What should the nurse do?

A)Use white-out over the mistake.
B)Take a wide permanent marker and blacken out all the documentation.
C)Put an "X" through the entire page,identify it as an "error," initial,and move on to the correct chart.
D)Draw a single line through the documentation,write "mistaken entry" next to the original entry,and initial it.

Question 17

When responding to a call light,the nurse finds a client lying on the floor,with the bed linens around the legs.Which chart entry should the nurse document for this finding?

A)Client fell out of bed,but did push the call button for assistance.
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 found on floor,appeared to have fallen out of bed as a result of getting tangled in bed linens.

Question 18

The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format,in which category should the nurse document this statement?

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

Question 19

The nurse is teaching medication administration to a client being discharged.Which instruction should the nurse rewrite for this client?

A)Lasix,20 mg,po bid
B)Lasix,20 mg tablet,twice daily
C)Lasix,20 mg by mouth,two times a day a day
D)Lasix,20 mg by mouth 8 AM and 2 PM

Question 20

A cardiac specialty hospital has several written plans in place for clients who are admitted,according to specific medical diagnoses and nursing interventions.Typical nursing diagnoses as well as standard nursing interventions are included in these plans.Which type of form is this hospital utilizing?

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

Question 21

A client's condition has deteriorated and the nurse needs to notify the health care provider.What information should the nurse include when providing a telephone report on this client?
Standard Text: Select all that apply.

A)Client's medical diagnosis
B)Name of unit nurse manager
C)Names of family members visiting
D)Name and relationship to the client
E)Observed changes in the client's status

Question 22

The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client care.Which actions should the nurse take to prove adherence?
Standard Text: Select all that apply.

A)Charting the client's response to pain medication taken
B)Describing the client as "appearing to be comfortable"
C)Leaving sufficient charting space for the previous shift to chart client teaching
D)Documenting that the client reports,"I'm so afraid of tomorrow's surgery"
E)Making a late entry regarding a client's request for pain medication

Question 23

The nurse is using I-SBAR to provide a report to an intensive care nurse for a client transfer.Which statements indicate that the nurse is using this communication technique appropriately?
Standard Text: Select all that apply.

A)"Mr.Collins has a history of peptic ulcer disease."
B)"Hi Susan,my name is Janie and I've been taking care of Mr.Collins all day."
C)"It's no wonder he's bleeding from his stomach;he drinks a six pack of beer every day."
D)"Late this morning Mr.Collins became nauseated and vomited 250 mL of bright red emesis."
E)"He has bowel sounds in all 4 quadrants,is not experiencing any pain,but has a heart rate of 110 and blood pressure of 98/50 mm Hg."

Question 24

The nurse is documenting care provided to a client.Which action should the nurse take to demonstrate the avoidance of potentially confusing abbreviations when documenting?
Standard Text: Select all that apply.

A)Documenting vital signs as "TPR."
B)Charting that the "drsg was dry and intact."
C)Transcribing a verbal order as "Carbamazepine 12 mcg/ml IV push daily."
D)Documenting "Client consistently requesting IM MS for pain well before prescribed time."
E)Charting,"Client to be ambulated q.i.d."