Deck 18: Documenting Reporting

Question 1

The department of nursing at a local hospital is considering changing to charting by exception (CBE).Which statement provides a rationale to support making this change?

A) Reduces the time nurses spend charting
B) Addresses the patient's concerns holistically
C) Establishes an ongoing care plan from admission
D) Is most useful when constructing a timeline of events

Answer 1

Reduces the time nurses spend charting

Question 2

A hospital uses a source-oriented medical record.What is a major disadvantage of this charting system?

A) It involves a cooperative effort among various disciplines.
B) The system requires diligence in maintaining a current problem list.
C) Data may be fragmented and scattered throughout the chart.
D) It allows the nurse to provide information in an unorganized manner.

Answer 2

Data may be fragmented and scattered throughout the chart.

Question 3

The nurse administers heparin 5,000 units subcutaneously at 2100 and documents in the medication administration record (MAR)that the dose was administered.What other information is important for the nurse to document?

A) Injection site
B) Previous site of administration
C) Patient response to medication
D) Heart rate prior to administration

Answer 3

Injection site

Question 4

A client is admitted to a long-term care facility.What does the nurse have to use to adhere to federal law?

A) The Minimum Data Set (MDS)for assessment
B) Situation-background-assessment-recommendation (SBAR)for reporting
C) Centers for Medicare and Medicaid Services (CMS)guidelines prior to surgery
D) The Joint Commission guidelines for discharge planning

Question 5

The patient's medical record contains the following documentation: 06/05/17 0200 Received patient from the E.D.BP 80/52,HR 118,RR 24,temp 104°F.Arouses to verbal stimuli but drifts off to sleep.Normal saline infusing in left arm via 18-gauge IV catheter at 250 mL/hr.Urinary catheter draining scant dark amber urine.Pt receiving O₂ at 6 L/min via nasal cannula.Lungs with coarse crackles at the left base.Loose cough present.Pt unable to expectorate secretions.-Ann Davids,RN
Which type of charting has the nurse used?

A) Narrative
B) Focus
C) SOAP
D) PIE

Question 6

The nursing instructor is teaching the student about occurrence reports.Which statement by the student indicates an understanding of the purpose of occurrence reports?

A) "Occurrence reports track problems and identify areas for quality improvement."
B) "Occurrence reports are required by the Food and Drug Administration to report drug errors."
C) "The Joint Commission requires occurrence reports for all client falls."
D) "Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."

Question 7

What is the purpose of completing an occurrence report?

A) Provide a legal defense should the patient seek legal action after an unusual occurrence
B) Track problems and identify areas for quality improvement
C) Report errors to the Food and Drug Administration
D) Report medical errors to The Joint Commission

Question 8

The patient's health record contains the following provider's order: furosemide 40 mg intravenously STAT.Where should the nurse look to determine whether the medication was provided and the patient's response?

A) Progress notes
B) Graphic record
C) Narrative notes
D) MAR

Question 9

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility?

A) 14 days
B) 3 days
C) 2 days
D) 24 hours

Question 10

A patient refuses a dose of medication.How should the nurse document the event?

A) Patient is uncooperative and refuses the prescribed dose of digoxin.
B) Patient refuses the 0900 dose of digoxin.
C) Patient is belligerent and argumentative and refuses the 0900 dose of digoxin.
D) 0900 dose of digoxin not given.

Question 11

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1-hour PRN pain.When should the nurse administer the medication?

A) Every hour around the clock
B) Immediately after taking off the order
C) As needed,but not more than once per hour
D) 1 hour after the last administered dose

Question 12

The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer.The order states: OOB in AM.Which action indicates that the nurse is following the surgeon's order?

A) Performs oral care
B) Assists the patient out of bed
C) Assists the patient with bathing
D) Changes the patient's operative dressings

Question 13

The nurse receives a telephone verbal order for pain medication for a client: morphine 4 mg intravenously every hour as needed for pain.How should the nurse document this telephone order?

A) 09/02/17 0845 morphine 4 mg intravenously q 1 hour PRN pain.Kay Andrews,RN
B) 09/02/17 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr.D.Kelly/Kay Andrews,RN
C) 09/02/17 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr.D.Kelly/Kay Andrews,RN
D) 09/02/17 0845 morphine 4 mg intravenously q 1 hour V.O.Kay Andrews,RN

Question 14

A client with respiratory failure is experiencing cyanosis and labored breathing.What action should the nurse take first?

A) Study the discharge plan.
B) Check the graphic data for vital signs.
C) Examine the history and physical.
D) Look for an advance directive.

Question 15

At 1000 on 11/14/17,the nurse receives a telephone order for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order?

A) 11/14/17 at 1200
B) 11/14/17 at 2200
C) 11/15/17 at 1000
D) 11/16/17 at 1000

Question 16

A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer.How often must the nurse document this patient's care?

A) Every 2 weeks
B) Every shift
C) Every week
D) Every 3 months

Question 17

The nurse makes a mistake while documenting in the patient's health record.Which action should the nurse take?

A) Use an opaque white fluid to cover the documentation error.
B) Completely cover the documentation error with black ink.
C) Draw a line through the error and initial the change.
D) Use correction tape to make the documentation correct.

Question 18

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer.Which integrated plan of care (IPOC)would be most appropriate for the nurse to implement?

A) Hypertension
B) Rheumatoid arthritis
C) Postoperative colon resection
D) Follow all three plans

Question 19

A patient is admitted to the emergency department with a stroke.After the patient has been stabilized,which information should the nurse include in the care plan that best meets the patient's needs?

A) Acute interventions
B) Patient teaching
C) Discharge needs
D) Family health data

Question 20

The nurse receives a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours.Which action must the nurse take to ensure the accuracy of the order?

A) Repeat the order to the prescriber even if she believes she understood the order correctly.
B) Immediately notify the pharmacy of the order and verify it with a pharmacist.
C) Ask the unit secretary to listen to the prescriber on the phone to verify the order.
D) Transcribe the order on note paper and verify the dosage in a drug handbook.

Question 21

Which is a disadvantage of paper health records?

A) Assist collaboration
B) Provide cautionary reminders
C) Are sometimes illegible
D) Serve as a resource

Question 22

Which set of topics makes up a hand-off report given in a recommended format?

A) Data-action-response
B) Subjective-objective-assessment-plan
C) Situation-background-assessment-recommendation
D) Patient-diagnosis-medications-activity

Question 23

When performing a hand-off report,the nurse should communicate information on which aspect of care? Select all that apply.

A) Teaching performed
B) Any change in client status
C) Treatments administered
D) Hygiene measures performed
E) Routine care provided

Question 24

Which action by the nurse breaches patient confidentiality? Select all that apply.

A) Leaving patient data displayed on a computer screen where others are able to view them
B) Remaining logged on to the computer system after documenting patient care
C) Faxing a patient report to the nurses' station at the facility where the patient is being transferred
D) Informing the nurse manager of a change in the patient's condition
E) Reviewing the medical record of a next-door neighbor admitted for a health problem

Question 25

Which statement by the student nurse indicates an understanding of the nursing Kardex^®? Select all that apply.

A) "The Kardex^® pulls data from multiple areas of the patient's chart."
B) "The Kardex^® is usually kept at the patient's bedside."
C) "The Kardex^® is used to document patient response to interventions."
D) "The Kardex^® summarizes the plan of care and guides nursing care."
E) "The Kardex^® is a portable file of patient information."

Question 26

During an admission assessment the nurse learns that a client has an allergy to penicillin.Where should the nurse document this information after including it in a note in the medical record?

A) MAR
B) Kardex^®
C) Bedside clipboard
D) Above the client's bed

Question 27

What should the nurse understand as being advantages of an electronic health record (EHR)? Select all that apply.

A) Facilitate evidence-based nursing practice
B) Promote efficient use of the nurse's documentation time
C) Reduce the opportunity for interdisciplinary collaboration
D) Ensure improved client safety and outcomes
E) Reduce cost for documenting care electronically

Question 28

Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply.

A) "I can wait until the end of the shift to document my care."
B) "Charting every 2 hours is the most appropriate way to document nursing care."
C) "I find it easier to chart before I go to lunch and then after my shift report."
D) "I should chart as soon as possible after nursing care is given."
E) "I document medications given before providing them to the patient."

Question 29

The nursing assistive personnel (NAP)informs the nurse that a patient has fallen out of bed and is in pain.The nurse assesses the patient and provides care.How should the nurse document the patient's fall?

A) Patient found on floor in pain after falling out of bed.
B) Patient found on floor after falling out of bed; found by NAP Smith.
C) Patient fell out of bed but is currently in bed.
D) Patient reminded to not climb OOB after falling.

Question 30

The nurse notes that a risk management nurse reviews the medical records of several clients on a care area.For what purpose is this review being performed?

A) Calculating the cost of care
B) Monitoring health status over time
C) Gathering data for clinical research
D) Determining whether interventions were appropriate