Test Bank Documentation and Informatics Potter & Perry: Fundamentals of Nursing, 7th Edition
Chapter 26: Documentation and Informatics
MULTIPLE
... [Show More] CHOICE
1. 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 col- leagues?
1. Audit of client care procedures
2. The client’s diagnostic-related group
3. All routine care procedures required by the client
4. Instructions given to the client in a teach- ing plan
ANS: 4
A change-of-shift report should include instructions given in a teaching plan and the cli- ent’s response. This should not include detailed content unless staff members ask for cla- rification. The nurse should relay to staff significant changes in the way therapies are giv- en, but should not describe basic steps of a procedure. The client’s diagnosis-related group is not essential background information to be shared in an inter-shift report. The nurse should not review all routine care procedures or tasks.
DIF: A REF: 399 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
2. 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?
1. The witnessing nurse completes the re- port.
2. Details of the incident are subjectively de- scribed.
3. An explanation of the possible cause for the incident is entered.
4. A notation is included in the medical re- cord that an incident report was prepared.
ANS: 1
The nurse who witnessed the incident is the one who completes the report. Details of the incident should be objectively described. An explanation of the possible cause is not in- cluded. The sequence of events is described objectively. A notation is not included in the medical record that an incident report was written.
DIF: A REF: 403 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
3. Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?
1. 1230—Client’s vital signs taken.
2. 0700—Client drank adequate amount of fluids.
3. 0900—Demerol given for lower abdomin- al pain.
4. 0830—Increased IV fluid rate to 100 mL/hr according to protocol.
ANS: 4
Information within a recorded entry needs to be complete, containing appropriate and es- sential information. This notation (0830) provides the time and action taken by the nurse including the reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry (0700) does not provide the specific amount the client drank. Stating “adequate” is subjective, not objective. This notation (0900) does not have the client de- scribe his or her pain or rate it according to a pain scale for comparison later. It also does not indicate whether the client’s pain was in the lower left or lower right quadrant, or both.
DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
4. The nurse makes a late entry in a client’s record. Which of the following is the best ex- ample of how to document this type of situation?
1. “2:45 PM—ASA gr X given for temperat- ure of 38.1° C.”
2. “8:30 AM—Client received Percodan (1 tablet) PO an hour before going to radi- ology.”
3. “12:15 PM—I gave the client morphine 10 mg IM at 11:10 AM but did not document it then.”
4. “8:30 PM—Abdominal dressing change at 7:30 PM. No s/s of infection, and wound edges approximating well.”
ANS: 1
This is the best example of a late entry. The time (2:45 PM) is indicated along with the ac- tion and an objective observation. This notation (8:30 AM) is not complete. It does not in- dicate why the Percodan was given. What was the client’s level of pain? Where was the
pain located? The nurse does not need to document about herself; only the client. In this option (12:15 PM), the nurse does not indicate why the morphine was given (client’s level of pain? location of pain?). This entry (8:30 PM) is not complete. It does not state the size of the wound, type of dressing used, or the client’s tolerance of the procedure.
DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
5. The following statement: “Upon exertion, the client is wheezing and experiencing some dyspnea,” is an example of:
1. The “P” of PIE
2. FOCUS documentation
3. The “R” in DAR documentation
4. The “S” in SOAP documentation
ANS: 1
These data are examples of the “P” of PIE because they describe the problem. FOCUS charting does not concentrate on only problems. It is structured according to a client’s concerns. The “R” in DAR documentation is the response of the client. This situation de- scribes the client’s problem, not the client’s response. The “S” in SOAP documentation represents subjective data (verbalizations of the client).
DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
6. To locate the recording of a nurse’s description of the teaching provided to the client on performance of self-medication administration, one would look in a(n):
1. Kardex
2. Incident report
3. Nursing history form
4. Discharge summary form
ANS: 4
A nurse’s description of the teaching provided to the client on performance of self-medic- ation administration is recorded in the discharge summary form. A Kardex is a written form that contains basic client information. A Kardex contains an activity and treatment section and a nursing care plan section that organizes information for quick reference as nurses give change-of-shift report. It does not include a description of teaching that was provided to the client. An incident report is any event that is not consistent with the routine operation of a health care unit or routine care of a client (e.g., a client falls). A nursing history form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems. It provides baseline data about the client.
DIF: A REF: 397-398 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
7. 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:
1. Draw a straight line through the error and initial it.
2. Erase the error and write over the material in the same spot.
3. Use a dark color marker to cover the error and continue immediately after that point.
4. Footnote the error at the bottom of the page.
ANS: 1
If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible. Also, entries should only be made in ink so they cannot be erased. Using a dark color marker to cover the er- ror is not correct. It may appear as if the nurse was attempting to hide something or de- face the record. Footnotes are not used in nursing documentation.
DIF: A REF: 388-389 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
8. The new staff nurse is having her documentation evaluated by the charge nurse. On re- view of her charting, the charge nurse notes that there is evidence of appropriate docu- mentation when the new staff nurse:
1. Uses a pencil to make the entries
2. Uses correction fluid to correct written er- rors
3. Identifies an error made by the attending physician
4. Dates and signs all of the entries made in the record
ANS: 4
Each entry should begin with the time and end with the signature and title of the person recording the entry. All entries should be recorded legibly and in black ink because pencil can be erased. The nurse should never erase entries, never use correction fluid, or never use a pencil. The use of correction fluid could make the charting become illegible and it may appear as if the nurse were attempting to hide something or to deface the record. If the physician made an error, the nurse should not document it in the client’s chart. It should be documented in an incident report.
DIF: A REF: 389 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
9. What is the correct response for the licensed practical nurse that answers the phone to re- spond within the following scenario? The physician calls to leave orders late at night for one of his clients.
1. “Let me get the Registered Nurse on the phone.”
2. “I am unable to take the order at this time. Please call in the morning.”
3. “Please repeat the order for me so I can make sure it is written correctly.”
4. “Let me have your phone number and I will have the supervisor call you back.”
ANS: 1
A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. Saying that an order is unable to be taken and to call back in the morn- ing is not an appropriate response and not in the client’s best interest. It is best to repeat any prescribed orders back to the physician, who can then verify if it is correct or clarify the order. This is not the appropriate response. A registered nurse needs to take the verbal order, but it does not have to be the nursing supervisor.
DIF: A REF: 402 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
10. 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?
1. “Infiltrated IV line”
2. “My arm feels better”
3. “Elevation of left forearm”
4. “Slight hematoma on left forearm”
ANS: 2
The “R” in FOCUS charting is the client’s response. In this case, the nurse would docu- ment, “My arm feels better.” “Infiltrated IV line” would be documented as “D” referring to data in FOCUS charting. “Elevation of left forearm” is the “A” in FOCUS charting. It describes the action or nursing intervention. “Slight hematoma on left forearm” is the “D” referring to data in FOCUS charting.
DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
11. Which of the following is evaluated as a legally appropriate notation?
1. “Dr. Green made an error in the amount of medication to administer.”
2. “Verbalized sharp, stabbing pain along the left side of chest.”
3. “Nurse Williams spoke with the client about the surgery.”
4. “Client upset about the physical therapy.”
ANS: 2
Entries should be concise, factual, and accurate. “Verbalized sharp, stabbing pain along the left side of chest” is an example of an objective description of a client’s behavior. The nurse should not document “physician made error.” Instead, the nurse could chart that “Dr. Green was called to clarify order for medication administration.” The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry. Only objective descriptions of the client’s behavior should be recorded. For ex- ample: Client states, “I don’t want physical therapy! I want to go home!”
DIF: A REF: 388-389 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
12. To avoid legal risks and possible lack of confidentiality associated with computerized documentation, many programs currently have:
1. Periodic changes in staff passwords
2. Thumbprint identification restrictions
3. All nursing staff uses the same access code
4. Only centralized medical records use the client data
ANS: 1
A good system of computerized documentation requires periodic changes in personal passwords to prevent unauthorized persons form tampering with records. Many programs do not have thumbprint identification restrictions. All nurses do not use the same access code. Each nurse should have his or her own password. Only centralized medical records using the client data is not a true statement. Authorized health care providers from any department can access and use the data.
DIF: A REF: 406 OBJ: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
13. Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy?
1. “Medicare reviews client charts to determ- ine care given.”
2. “Good charting results in good Medicare reimbursement.”
3. “Our nursing salaries are paid for by the Medicare reimbursement funds.”
4. “The hospital is reimbursed for the nurs- ing care documented in the client chart.”
ANS: 4
Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each diagnosis-related group (DRG). Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs.
DIF: C REF: 387 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
14. The professional nurse realizes there is both a legal and an ethical obligation to keep cli- ent information obtained through examination, observation, conversation, or treatment:
1. Secured
2. Accessible
3. Confidential
4. Documented
ANS: 3
Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a client’s examination, observation, conversation, or treatment with other clients or staff not involved in the client’s care. The other options are primarily directed towards written records and are not ethically oriented.
DIF: A REF: 385 OBJ: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
15. Which of the following nursing statements regarding the release of a client’s medical re- cord to another institution requires immediate follow-up by the nurse’s manager?
1. “I’m pretty sure this will require the cli- ent’s permission.”
2. “Are you sure of the exact policy? Do you know what I should do?”
3. “The client agreed to the consultation, so I’ll have the chart sent over.”
4. “I think the client will need to give a verbal consent before it can be sent.”
ANS: 3
Each institution has policies to control the manner for sharing records. In most situations, clients are required to give written permission for release of medical information. The
other options have the nurse asking for help or expressing doubt about the proper pro- tocol for the release of the records; these would be appropriate statements and the man- ager should provide the correct information.
DIF: C REF: 385 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
16. Regarding access to client records, the nursing faculty informs the nursing students to be prepared to:
1. Show the unit staff proper student identi- fication
2. Sign a confidentiality agreement when on the unit to preplan
3. Review the medical record only in the presence of unit staff
4. Obtain permission from the client to ac- cess his or her medical record
ANS: 1
When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, they obtain appropriate authoriza- tion according to agency policy. Nursing students and faculty may be required to present identification indicating access to the record is authorized. The remaining options are not required if the student is properly identified and shows need to access the material.
DIF: C REF: 385 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
17. Which of the following nursing actions is most directly aimed at affording a client con- fidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care?
1. Notifying the client of the institution’s privacy policy
2. Denying nonessential personal access to the client’s medical records
3. Acquiring the client’s verbal consent to share his or her medical record with es- sential personnel
4. Requiring that the client sign the Health Insurance Portability and Accountability Act (HIPAA) form
ANS: 1
Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in order to eliminate barriers that could delay access to care, required only that health care
providers notify clients of their privacy policy and make a reasonable effort to get written acknowledgment of this notification.
DIF: A REF: 385 OBJ: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
18. When another health care professional is asked to assess a client for the purpose of sug- gesting treatment to the primary health care provider, this is called a:
1. Referral
2. Consultation
3. Transfer report
4. Multidisciplinary meeting
ANS: 1
Referrals are the request for services by another care provider usually for the purpose of determining appropriate client care. Consultations are a form of discussion whereby one professional caregiver actually gives formal advice about the care of a client to another caregiver. The remaining options are methods of exchanging general information regard- ing a client.
DIF: A REF: 386 OBJ: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
19. Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?
1. “Client was angry because breakfast was not to her liking.”
2. “Client is depressed; was observed crying while alone in room.”
3. “Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists.”
4. “Client was verbally abusive to staff when approached concerning client’s continued attempts to smoke in the bathroom.”
ANS: 3
Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objectively describe the noted client behavior.
20. Which of the following nursing notations shows the greatest need for instruction regard- ing the need to document only objective client assessment data?
1. “Client was angry because breakfast was not to her liking.”
2. “Client is depressed; was observed crying while alone in room.”
3. “Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists.”
4. “Client was verbally abusive to staff when approached concerning client’s continued attempts to smoke in the bathroom.”
ANS: 2
Do not write personal opinions. Document observable, measurable client-oriented data only. Recording that the client is depressed based on the observation of tears is not ob- jective and so is not acceptable. While one option does report only observable, measur- able behavior, the remaining options, while noting observed client behavior, do fail to ob- jectively describe the noted client behavior.
21. Which of the following statements made by a nurse most reflects a need for additional in- struction on areas of client care requiring nursing documentation?
1. “The fact that the client refused the pre- scribed antidepressant medication was noted in his chart.”
2. “I provided a detailed description of the dressing change in the client’s chart in or- der to show it was done as prescribed.”
3. “The client’s wife told me he often devel- ops a rash when he comes into contact with scented soaps, so I noted that in his chart.”
4. “I had a long conversation with the client concerning his fears about his upcoming surgery and I mentioned his concerns in my nursing note.”
ANS: 2
Common charting mistakes that can result in malpractice include the following: (1) fail- ing to record pertinent health or drug information; (2) failing to record nursing actions;
(3) failing to record that medications have been given; (4) failing to record drug reactions or changes in client’s condition; (5) writing illegible or incomplete records; and (6) fail- ing to document a discontinued medication. Detailed descriptions of procedures are not included in the nursing notes.
DIF: C REF: 388 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
22. The nursing faculty recognizes the correct way to instruct the nursing students to ac-
knowledge their charting in a client’s medical record is:
1. James Thicket, NS, WVU
2. J. Jones, NS, Montclair Shores College
3. N.H, SN, Bellfield City Community Col- lege
4. Linda Mozden, SN, Fairmont State Uni- versity
ANS: 4
A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and edu- cational institution, such as “David Jones, SN (student nurse), CMTC (Central Maine Technical College).”
DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
23. The nurse realizes that the incorrect spelling of terms in the medical record most import- antly:
1. Shows a lack of competency
2. Displays little attention to detail
3. Contributes to serious treatment errors
4. Negatively affects the accuracy of the documentation
ANS: 3
Spelling errors can result in serious treatment errors; for example, the names of certain medications such as digitoxin and digoxin or morphine and Numorphan are similar. Mis- spelling such terms can result in medication errors that may cause serious harm to a cli- ent. The other options are correct but do not have the seriousness of client care errors.
DIF: C REF: 389 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
24. Related to Problem Oriented Medical Record (POMR) documentation, which of the fol- lowing statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?
1. “His surgery corrected the mobility prob- lem, so I drew a line through it and dated it.”
2. “The client’s problem list has several re- solved problems on it; should I take them off?”
3. “The client no longer has anxiety issues so I highlighted that problem on his problem
list.”
4. “He doesn’t experience any dizziness now that we have his medication regulated, so I’ve erased that from his problem list.”
ANS: 4
New problems are added as they are identified. When a problem has been resolved, re- cord the date and highlight it or draw a line through the problem and its number. Erasure is not an acceptable method of showing that a problem has been resolved.
DIF: A REF: 390-391 OBJ: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
25. Which of the following is an example of a problem statement used in the Problem-Inter- vention-Evaluation documentation method?
1. Risk for injury related to falling due to dizziness
2. Client fell while walking to bathroom un- assisted
3. Client continues to report periods of dizzi- ness upon sitting up
4. Educated to the purpose of dangling on the bedside before standing
ANS: 1
The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the client’s objective or subjective response to the nursing intervention.
DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
26. Which of the following is an example of an intervention used in the Problem-Interven- tion-Evaluation documentation method?
1. Risk for injury related to falling due to dizziness
2. Client fell while walking to bathroom un- assisted
3. Client continues to report periods of dizzi- ness upon sitting up
4. Educated to the purpose of dangling on the bedside before standing
ANS: 4
The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the client’s objective or subjective response to the nursing intervention.
DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Safe, Effective Care Environment [Show Less]