Deck 3: Managing Client Care: Documentation and Delegation

Question 1

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.

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

Answer 1

Impaired skin integrity.

Question 2

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

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.

Answer 2

They can chart hygienic care when flow sheet charting is used.

Question 3

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

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.

Answer 3

Only addresses client changes when the predetermined norm is not met.

Question 4

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

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 5

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."

Question 6

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?

Question 7

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

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

Question 8

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

Question 9

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.

Question 10

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

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

Question 11

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

Question 12

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

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 13

A major advantage of a computer-based documentation system is

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 14

Nursing care plans should be updated at least

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

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

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 16

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

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.