Question 1

Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data?

Accepted Answer

A)   "Client was angry because breakfast was not to her liking."
B)   "Client is depressed;was observed crying while alone in room."
C)   "Client expressed pain as an 8 out of 10,was diaphoretic,guarding her abdomen and clenching her fists."
D)   "Client was verbally abusive to staff when approached concerning client's continued attempts to smoke in the bathroom." B

Question 2

Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

Accepted Answer

A)   Risk for injury related to falling due to dizziness
B)   Client fell while walking to bathroom unassisted
C)   Client continues to report periods of dizziness upon sitting up
D)   Educated to the purpose of dangling on the bedside before standing A

Question 3

Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care?

Accepted Answer

A)   Notifying the client of the institution's privacy policy
B)   Denying nonessential personal access to the client's medical records
C)   Acquiring the client's verbal consent to share his or her medical record with essential personnel
D)   Requiring that the client sign the Health Insurance Portability and Accountability Act (HIPA
A)  form A

Question 4

Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy?

Accepted Answer

A)   "Medicare reviews client charts to determine care given."
B)   "Good charting results in good Medicare reimbursement."
C)   "Our nursing salaries are paid for by the Medicare reimbursement funds."
D)   "The hospital is reimbursed for the nursing care documented in the client chart."

Question 5

To avoid legal risks and possible lack of confidentiality associated with computerized documentation,many programs currently have:

Accepted Answer

A)   Periodic changes in staff passwords
B)   Thumbprint identification restrictions
C)   All nursing staff uses the same access code
D)   Only centralized medical records use the client data

Question 6

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

Accepted Answer

A)   Risk for injury related to falling due to dizziness
B)   Client fell while walking to bathroom unassisted
C)   Client continues to report periods of dizziness upon sitting up
D)   Educated to the purpose of dangling on the bedside before standing

Question 7

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 inter-shift report to nursing colleagues?

Accepted Answer

A)   Audit of client care procedures
B)   The client's diagnostic-related group
C)   All routine care procedures required by the client
D)   Instructions given to the client in a teaching plan

Question 8

The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a client's medical record is:

Accepted Answer

A)   James Thicket,NS,WVU
B)   J.Jones,NS,Montclair Shores College
C)   N.H,SN,Bellfield City Community College
D)   Linda Mozden,SN,Fairmont State University

Question 9

Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?

Accepted Answer

A)   "Client was angry because breakfast was not to her liking."
B)   "Client is depressed;was observed crying while alone in room."
C)   "Client expressed pain as an 8 out of 10,was diaphoretic,guarding her abdomen and clenching her fists."
D)   "Client was verbally abusive to staff when approached concerning client's continued attempts to smoke in the bathroom."

Question 10

The nurse has made an error and is documenting such on the client's record and notes.The action that the nurse should take is to:

Accepted Answer

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

Question 11

Related to Problem Oriented Medical Record (POMR)documentation,which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

Accepted Answer

A)   "His surgery corrected the mobility problem,so I draw a line through it and dated it."
B)   "The client's problem list has several resolved problems on it;should I take them off?"
C)   "The client no longer has anxiety issues so I highlighted that problem on his problem list."
D)   He doesn't experience any dizziness now that we have his medication regulated,so I've erased that from his problem list."

Question 12

Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation?

Accepted Answer

A)   "The fact that the client refused the prescribed antidepressant medication was noted in his chart."
B)   "I provided a detailed description of the dressing change in the client's chart in order to show it was done as prescribed."
C)   "The client's wife told me he often develops a rash when he comes into contact with scented soaps,so I noted that in his chart."
D)   "I had a long conversation with the client concerning his fears about his upcoming surgery and I mentioned his concerns in my nursing note."

Question 13

The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination,observation,conversation,or treatment:

Accepted Answer

A)   Secured
B)   Accessible
C)   Confidential
D)   Documented

Question 14

The new staff nurse is having her documentation evaluated by the charge nurse.On review of her charting,the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:

Accepted Answer

A)   Uses a pencil to make the entries
B)   Uses correction fluid to correct written errors
C)   Identifies an error made by the attending physician
D)   Dates and signs all of the entries made in the record

Question 15

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

Accepted Answer

A)   Risk for injury related to falling due to dizziness
B)   Client fell while walking to bathroom unassisted
C)   Client continues to report periods of dizziness on sitting up
D)   Educated to the purpose of dangling on the bedside before standing

Question 16

An incident report is to be completed because the client climbed over the side rails and fell to the floor.The correct reporting of an incident involves which of the following?

Accepted Answer

A)   The witnessing nurse completes the report.
B)   Details of the incident are subjectively described.
C)   An explanation of the possible cause for the incident is entered.
D)   A notation is included in the medical record that an incident report was prepared.

Question 17

What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.

Accepted Answer

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 I can make sure it is written correctly."
D)   "Let me have your phone number and I will have the supervisor call you back."

Question 18

Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?

Accepted Answer

A)   1230-Client's vital signs taken.
B)   0700-Client drank adequate amount of fluids.
C)   0900-Demerol given for lower abdominal pain.
D)   0830-Increased IV fluid rate to 100 mL/hr according to protocol.

Question 19

The client developed a slight hematoma on his left forearm.The nurse labels the problem as an infiltrated intravenous (IV)line.The nurse elevates the forearm.The client states,"My arm feels better." What is documented as the "R" in FOCUS charting?

Accepted Answer

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

Question 20

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

Accepted Answer

A)   "Dr.Green made an error in the amount of medication to administer."
B)   "Verbalized sharp,stabbing pain along the left side of chest."
C)   "Nurse Williams spoke with the client about the surgery."
D)   "Client upset about the physical therapy."

Exam 26: Documentation and Informatics

Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data?

Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care?

Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy?

To avoid legal risks and possible lack of confidentiality associated with computerized documentation,many programs currently have:

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

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 inter-shift report to nursing colleagues?

The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a client's medical record is:

Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?

The nurse has made an error and is documenting such on the client's record and notes.The action that the nurse should take is to:

Related to Problem Oriented Medical Record (POMR) documentation,which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation?

The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination,observation,conversation,or treatment:

The new staff nurse is having her documentation evaluated by the charge nurse.On review of her charting,the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

An incident report is to be completed because the client climbed over the side rails and fell to the floor.The correct reporting of an incident involves which of the following?

What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.

Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?

The client developed a slight hematoma on his left forearm.The nurse labels the problem as an infiltrated intravenous (IV) line.The nurse elevates the forearm.The client states,"My arm feels better." What is documented as the "R" in FOCUS charting?

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