Chapter 15 Documenting and Reporting Potter et al Canadian Fundamentals of Nursing, 6th Ed, Exams of Nursing

Download Chapter 15 Documenting and Reporting Potter et al Canadian Fundamentals of Nursing, 6th Ed and more Exams Nursing in PDF only on Docsity!

Chapter 15 Documenting and Reporting

Potter et al Canadian Fundamentals of

Nursing, 6th Edition Test Bank

A nurse preceptor is supervising a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. The student nurse reviews the patient's medical record. b. The student nurse reads the patient's plan of care. c. The student nurse shares patient information with a friend. d. The student nurse documents medication administered to the patient. - ANS: c. The student nurse shares patient information with a friend.

2. A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete? - ANS: A report. Which situation best indicates that the nurse has a good understanding of auditing and monitoring patients' health records? a. The nurse determines the degree to which standards of care are met by reviewing patients' health records. b. The nurse realizes that care not documented in patients' health records still qualifies as care provided. c. The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. d. The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment. - ANS: a. The nurse determines the degree to which standards of care are met by reviewing patients' health records. After providing care, a nurse charts in the patient's record. Which entry should the nurse document? a. "Appears restless when sitting in the chair" b. "Drank adequate amounts of water" c. "Apparently is asleep with eyes closed" After providing care, a nurse charts in the patient's record. Which entry should the nurse document?

a. "Appears restless when sitting in the chair" b. "Drank adequate amounts of water" c. "Apparently is asleep with eyes closed" - ANS: d. "Skin pale and cool" A nurse has provided care to a patient. Which entry should the nurse document in the patient's record? a. "Patient seems to be in pain and states, 'I feel uncomfortable.'" b. "Status unchanged, doing well." c. "Left abdominal incision 5 cm in length without redness, drainage, or edema." d. "Patient is hard to care for and refuses all treatments and medications. Family present." - ANS: c. "Left abdominal incision 5 cm in length without redness, drainage, or edema." A preceptor is supervising a new nurse on documentation. Which situation will cause the preceptor to intervene? - ANS: The new nurse charts consecutively on every other line. A nurse is charting on a patient's record. Which action is most accurate legally? - ANS: Charting legibly. A nurse wants to integrate all pertinent patient information into one record, regardless of the number of times a patient enters the health care system. Which term should the nurse use to describe this system?

• ANS: Electronic health record. A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting? - ANS: "Patient demonstrated use of crutches." A nurse is using the source record and wants to find the patient's daily weights. Where should the nurse look? - ANS: Graphic sheet and flow sheet.. A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? - ANS: Document the variance in the patient's record.

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a productive cough. When is the best time for the nurse to start discharge planning for this patient? - ANS: a. Upon admission.

13. A patient is being discharged home. Which information should the nurse include? - ANS: Community resources. A nurse developed the following discharge summary sheet. Which critical information should be added? TOPIC: DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge a. Kardex form b. Admission nursing history c. Mode of transportation d. SOAP notes - ANS: c. Mode of transportation According to documentation guidelines the most appropriate notation is a. "1230 hours: Patient's vital signs taken." b. "0700 hours: Patient drank adequate amount of fluid." c. "0900 hours: Morphine given for lower abdominal pain." d. "0830 hours: Increased IV fluid rate to 100 mL per hour." - ANS: d. "0830 hours: Increased IV fluid rate to 100 mL per hour."

The final "R" when using the I-SBAR-R communication technique represents which of the following? - ANS: Repeat back. A nurse is giving a hand-off report to the nurse on the next shift. Which information is critical for the nurse to report? - ANS: The patient has a new pain medication, hydrocodone bitartrate and acetaminophen (Lortab). A new nurse asks the preceptor why a change-of-shift report is important, inasmuch as care is documented in the chart. What is the preceptor's best response? a. "A change-of-shift report provides an opportunity to share essential information to ensure patient safety and continuity of care." b. "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs." c. "A change-of-shift report provides an opportunity for the oncoming nurse to ask questions and determine research priorities." d. "A change-of-shift report provides important information to caregivers and develops relationships within the health care team." - ANS: a. "A change-of-shift report provides an opportunity to share essential information to ensure patient safety and continuity of care." A nurse is preparing a change-of-shift report for a patient who had chest pain. Which information is critical for the nurse to include? - ANS: "Sharp pain of 8 on a scale of 1 to 10." Which situation will require the nurse to obtain a telephone order? a. As the nurse and primary care provider leave a patient's room, the primary care provider gives the nurse an order. b. At 0100, a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood. c. At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order. d. A nurse reads an order correctly as written by the primary care provider in the patient's medical record. - ANS: b. At 0100, a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood.

A nurse obtained a telephone order (TO) from a primary care provider for a patient in pain. Which chart entry should the nurse document? a. "12/16/20, 0915: Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back." b. "12/16/20, 0915: Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back." c. "12/16/20, 0915: Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back." d. "12/16/20, 0915: Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN." - ANS: c. "12/16/20, 0915: Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back."

22. A nurse records the following: "Patient is wheezing and experiencing some dyspnea on exertion." This represents which of the following? The "S" in SOAP documentation. Focus documentation. The "P" of PIE documentation. The "R" in DAR documentation. - ANS: The "P" of PIE documentation. A hospital is using computer software that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? - ANS: Critical pathway design. A nurse wants to reduce data entry errors on the computer system. Which behaviour should the nurse implement? - ANS: Chart on the computer immediately after care is provided. Which entry will require follow-up by the nurse manager? a. 0800: Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Call bell within reach. Bed monitor on. -------------------Jane More, RN b. 0810: Notified primary care provider of patient's status. New orders received. -------------------Jane More, RN

c. 0815: Portable x-ray of L hip taken in room. Patient states, "I feel fine." -------------------Jane More, RN d. 0830: Incident report completed and placed on chart. -------------------Jane More, RN - ANS: d. 0830: Incident report completed and placed on chart. -------------------Jane More, RN The action that a nurse would take when documenting on the patient's record and notes that he or she has made an error is which of the following? a. Drawing a line through the error and initialing and dating it. b. Erasing the error and writing over the material in the same spot. c. Using a dark-coloured marker to cover the error and continuing immediately after that point. d. Footnoting the error at the bottom of the page, including initials and the date. - ANS: a. Drawing a line through the error and initialing and dating it. 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." When using the DAR notes of focus charting, the nurse would document the "R" as which of the following? - ANS: "My arm feels better." A nurse is discussing the advantages of standardized documentation forms in the nursing information system. Which advantage should the nurse describe? - ANS: Reduced errors of omission. Identify the purposes of a health care record. (Select all that apply.) a. Communication. b. Legal documentation. c. Reimbursement. d. Education. e. Research. f. Nursing process. - ANS: a. Communication. b. Legal documentation. d. Education.

e. Research. A nurse is creating a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) A nurse is creating a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) a. Create a password with just letters. b. Bypass the firewall. c. Use a programmed speed-dial key when faxing. d. Implement an automatic sign-off. e. Impose disciplinary actions for inappropriate access. f. Shred papers containing personal health information. - ANS: c. Use a programmed speed-dial key when faxing. d. Implement an automatic sign-off. e. Impose disciplinary actions for inappropriate access. f. Shred papers containing personal health information. A manager is reviewing the nurses' notes in a patient's medical record. She finds the following entry: "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions should the manager give to the staff nurse who entered the note? - ANS: Enter only objective and factual information about the patient. A patient tells the nurse, "I have stomach cramps and feel nauseated." This is an example of which type of data? - ANS: Subjective As the nurse enters the patient's room, the nurse notices that he is anxious to say something. The patient quickly exclaims, "I don't know what's going on; I can't get an explanation from my doctor about the results of my test. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? - ANS: The patient stated that he felt frustrated by the lack of information he has received regarding his diagnostic tests. Correct Patients frequently request copies of their medical records. The nurse understands that which of the following is correct? - ANS: Patients have the right to read their records

Accurate entries are an important characteristic of good documentation. Which of the following charting entries is most accurate in the way it is written? - ANS: Patient ambulated 15 m and back down hallway with assistance from nurse, heart rate 88 and regular before exercise, 94 and regular after exercise. Correct Which of the following represents a breach of confidentiality and privacy? - ANS: A nurse telephones the patient's church to have the patient's name placed on a prayer list Which of the following is one purpose of the patient's medical record? - ANS: Education and research Which of the following is a guideline for legally sound documentation? - ANS: If an order is questioned, record that clarification was sought Which of the following is the best example of quality documentation? - ANS: 6-cm incision on right lower quadrant, edges pink and well approximated with sutures; no drainage noted When a nurse follows the SOAP method of charting, the information the nurse would record under "O" would be which of the following? - ANS: Right foot is red with +4 pitting edema and capillary refill less than 3 seconds Which of the following is a method of charting in which the nurse writes a progress note only when the standardized statement on the form is not met? - ANS: Charting by exception Why are critical pathways a valuable tool in patient care? - ANS: They provide members of the health care team with a way to document their contributions to the patient's total plan of care. Which of the following is one advantage of standardized care plans? - ANS: They establish clinically sound standards of care for similar groups of patients A nursing instructor is helping a student nurse with discharge planning for a patient. The instructor realizes that further education is needed when the student nurse says which of the following? - ANS: "I really can't start discharge planning until the physician writes the discharge orders."

The nurse is giving a change-of-shift report. Which of the following is the most appropriate report statement? - ANS: David Jackson, in 121-1, a 92-year-old patient of Dr. Able, is here with pneumonia. He is receiving oxygen at 2 L per nasal cannula. He has crackles in his right lower lobe, clear rest. He can get up with assistance of one. He has been coughing up thick, yellow-tinged sputum after his breathing treatments. He gets them every 6 hours. His next treatment will be at 0800. A patient is complaining of pain at 0400 hours. The nurse telephones Dr. Rice and receives an order for oxycodone hydrochloride, 5 mg, one tablet every 4 hours as needed. It is wise for the nurse to do which one of the following? - ANS: Repeat the prescribed order back to the physician.