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Documenting & Reporting
| Question | Answer |
|---|---|
| With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? | any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders |
| The nurse cared for a client admitted with uncontrolled hypertension. The client suffered a stroke shortly after the nurse’s shift ended. Which information will determine if the nurse is liable? | Omitting documentation of blood pressure at the end of the shift |
| A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn’t violate client privacy because I didn’t use the client's name." What response by the nurse manager is most appropriate? | "Any information that can identify a person is considered a breach of client privacy." |
| The nurse documents a progress note in the wrong client’s electronic medical record (EMR). Which action would the nurse take once realizing the error? | Create an addendum with a correction |
| Which principle should guide the nurse's documentation of entries on the client's health care record? | Precise measurements should be used rather than approximations |
| The nurses at a health care facility were informed of the change to organize the clients’ records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? | Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers |
| Nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? | "I think the client would benefit from intravenous furosemide." |
| Which are appropriate actions for protecting clients’ identities? | Document all personnel who have accessed a client’s record. Place light boxes for examining X-rays with the client’s name in private areas. Have conversations about clients in private places where they cannot be overheard. |
| A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? | "It will allow for us to see the client and possibly increase client participation in care." |
| A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information? | You can fill in information from your own records and store it on your computer or the Internet." |
| When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: | Interpretation of data-This is an interpretation of the client's behavior and not a factual statement |
| The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? | Remind the UAP about the client's right to privacy |
| The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? | -Showing the provider the trends from baseline to present in blood pressure-Informing the provider of the client's present heart rate of 116 beats/min-Faxing the results of blood chemistry levels to the provider's office |
| Which is the primary purpose of client records? | Communication-Communication fosters continuity of care |
| The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? | Inform the health care provider that a written order is needed-Verbal orders should only be accepted during an emergency |
| Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? | A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart-Among the provisions of HIPAA are clients' rights to see and read their medical records |
| The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? | Subjective data should be included when documenting-This is data that only the patient can tell you because it is their thoughts/feelings |
| The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? | “Only authorized persons are allowed to access client records.”-The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records |
Created by: kmeans34
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