Documenting, Reporting, Conferring, And Using Informatics

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Questions: 36 | Attempts: 653

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Questions and Answers
  • 1. 

    A client’s diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client’s chart should be written as

    • A.

      Avelox (moxifloxacin) 400 mg daily

    • B.

      Avelox (moxifloxacin) 400 mg Q.D.

    • C.

      Avelox (moxifloxacin) 400 mg qd

    • D.

      Avelox (moxifloxacin) 400 mg OD

    Correct Answer
    A. Avelox (moxifloxacin) 400 mg daily
    Explanation
    Ans:
    A
    Feedback:
    Among the JCAHO’s list of “do not use” abbreviations are Q.D., qd, and OD when denoting a once-per-day drug administration. Because of the potential for misinterpretation and consequent drug errors, the JCAHO recommends writing “daily” in the order.

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  • 2. 

    The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?

    • A.

      Vulnerability to legal liability since nurse’s safe, routine care is not recorded

    • B.

      Increased workload for nurses in order to complete necessary documentation

    • C.

      Failure to identify and record client problems and associated interventions

    • D.

      OSignificant differences in the charting between nurses due to lack of standardizationption 4

    Correct Answer
    A. Vulnerability to legal liability since nurse’s safe, routine care is not recorded
    Explanation
    Ans:
    A
    Feedback:
    A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

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  • 3. 

    The nurse managers of a home health care office wish to maximize nurses’ freedom to characterize and record client conditions and situations in the nurses’ own terms. Which of the following documentation formats is most likely to promote this goal?

    • A.

      Narrative notes

    • B.

      SOAP notes

    • C.

      Focus charting

    • D.

      Charting by exception

    Correct Answer
    A. Narrative notes
    Explanation
    One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

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  • 4. 

    A hospital utilizes the SOAP method of charting. Within this model, which of the nurse’s following statements would appear at the beginning of a charting entry?

    • A.

      “Client complaining of abdominal pain rated at 8/10.”

    • B.

      “Client is guarding her abdomen and occasionally moaning.”

    • C.

      “Client has a history of recent abdominal pain.”

    • D.

      “2 mg Dilaudid PO administered with good effect”

    Correct Answer
    A. “Client complaining of abdominal pain rated at 8/10.”
    Explanation
    The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse’s objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

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  • 5. 

    What is the nurse’s best defense if a client alleges nursing negligence?

    • A.

      Testimony of other nurses

    • B.

      Testimony of expert witnesses

    • C.

      Client’s record

    • D.

      Client’s family

    Correct Answer
    C. Client’s record
    Explanation
    The client record is the only permanent legal document that details the nurse’s interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence.

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  • 6. 

    A nurse is documenting the intensity of a client’s pain. What would be the most accurate entry?

    • A.

      “Client complaining of severe pain.”

    • B.

      “Client appears to be in a lot of pain and is crying.”

    • C.

      “Client states has pain; walking in hall with ease.”

    • D.

      “Client states pain is a 9 on a scale of 1 to 10.”

    Correct Answer
    D. “Client states pain is a 9 on a scale of 1 to 10.”
    Explanation
    The most accurate entry would be "Client states pain is a 9 on a scale of 1 to 10." This entry provides a specific and quantifiable measure of the client's pain intensity, allowing for a more accurate assessment and comparison over time. The other options provide subjective descriptions of the client's pain but do not provide a clear indication of the intensity level.

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  • 7. 

    Which of the following data entries follows the recommended guidelines for documenting data?

    • A.

      “Client is overwhelmed by the diagnosis of pancreatic cancer.”

    • B.

      “Client’s kidneys are producing sufficient amount of measured urine.”

    • C.

      “Following oxygen administration, vital signs returned to baseline.”

    • D.

      “Client complained about the quality of the nursing care provided on previous shift.”

    Correct Answer
    C. “Following oxygen administration, vital signs returned to baseline.”
    Explanation
    The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as “good,” “average,” “normal,” or “sufficient,” which may mean different things to different readers.

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  • 8. 

    Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry?

    • A.

      AJRN

    • B.

      Alice J, RN

    • C.

      A. Jones, RN

    • D.

      Alice Jones

    Correct Answer
    C. A. Jones, RN
    Explanation
    Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is correct.

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  • 9. 

    A student has reviewed a client’s chart before beginning assigned care. Which of the following actions violates client confidentiality?

    • A.

      Writing the client’s name on the student care plan

    • B.

      Providing the instructor with plans for care

    • C.

      Discussing the medications with a unit nurse

    • D.

      Providing information to the physician about laboratory data

    Correct Answer
    A. Writing the client’s name on the student care plan
    Explanation
    Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.

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  • 10. 

    A physician’s order reads “up ad lib.” What does this mean in terms of client activity?

    • A.

      May walk twice a day

    • B.

      May be up as desired

    • C.

      May only go to the bathroom

    • D.

      Must remain on bed rest

    Correct Answer
    B. May be up as desired
    Explanation
    The phrase "up ad lib" means that the client is allowed to be up and engage in activities as desired. This indicates that there are no restrictions on their activity level and they are free to move around and participate in any activities they choose.

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  • 11. 

    In what type of documentation method would a nurse document narrative notes in a nursing section?

    • A.

      Problem-oriented medical record

    • B.

      Source-oriented record

    • C.

      PIE charting system

    • D.

      Focus charting

    Correct Answer
    B. Source-oriented record
    Explanation
    A source-oriented record is a type of documentation method where a nurse would document narrative notes in a nursing section. In this method, the nurse organizes the patient's medical information according to its source, such as separate sections for nursing notes, physician notes, laboratory reports, etc. This allows for easy retrieval of information by different healthcare professionals involved in the patient's care.

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  • 12. 

    Which one of the following methods of documentation is organized around client diagnoses rather than around patient information?

    • A.

      Problem-oriented medical record (POMR)

    • B.

      Source-oriented record

    • C.

      PIE charting system

    • D.

      Focus charting

    Correct Answer
    A. Problem-oriented medical record (POMR)
    Explanation
    The POMR is organized around a client’s problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care.

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  • 13. 

    A nurse organizes client data using the SOAP format. Which of the following would be recorded under “S” of this acronym?

    • A.

      Client complaints of pain

    • B.

      Client history

    • C.

      Client’s chief complaint

    • D.

      Client interventions

    Correct Answer
    A. Client complaints of pain
    Explanation
    The SOAP format (subjective data, objective data, Assessment [the caregiver’s judgment about the situation], plan) is used to organize data entries in the progress notes of the POMR. A client complaint of pain is subjective data (S).

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  • 14. 

    Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

    • A.

      Problem-oriented medical record

    • B.

      Charting by exception

    • C.

      PIE charting system

    • D.

      Focus charting

    Correct Answer
    B. Charting by exception
    Explanation
    Charting by exception is least likely to hold up in court if a case of negligence is brought against a nurse. This method involves documenting only significant findings or exceptions to the normal condition of the client. It does not provide a comprehensive record of the client's condition and the care provided. In a legal case, a thorough and detailed documentation is essential to prove that the nurse provided appropriate care and followed established protocols. Charting by exception may be seen as insufficient evidence of the nurse's actions and decision-making, which could weaken their defense in court.

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  • 15. 

    A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next?

    • A.

      Date it and put it in the client’s record.

    • B.

      Sign it and put it in the Kardex.

    • C.

      Individualize it to the specific client.

    • D.

      Use it as printed, based on common needs.

    Correct Answer
    C. Individualize it to the specific client.
    Explanation
    Standardized care plans that identify common problems and needs with relation to select client cohorts may be used. Unless such care plans are individualized to a specific client, however, they may not address individual client needs.

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  • 16. 

    What part of the client’s record is commonly used to document specific client variables, such as vital signs?

    • A.

      Progress notes

    • B.

      Nursing notes

    • C.

      Critical paths

    • D.

      Graphic record

    Correct Answer
    D. Graphic record
    Explanation
    The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements.

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  • 17. 

    A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?

    • A.

      PIE system

    • B.

      Minimum data set

    • C.

      OASIS

    • D.

      Charting by exception

    Correct Answer
    B. Minimum data set
    Explanation
    Long-term care documentation is specified by the RAI with the minimum data set forming the foundation for the assessment. This is required in all facilities certified to participate in Medicare or Medicaid. OASIS is used in the home health care industry

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  • 18. 

    What is the primary purpose of an incident report?

    • A.

      Means of identifying risks

    • B.

      Basis for staff evaluation

    • C.

      Basis for disciplinary action

    • D.

      Format for audiotaped report

    Correct Answer
    A. Means of identifying risks
    Explanation
    An incident report, also termed a variance or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. Incident reports should not be used for disciplinary action against staff members.

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  • 19. 

    A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called?

    • A.

      Nursing care conferences

    • B.

      Staff visits

    • C.

      Interdisciplinary referrals

    • D.

      Nursing care rounds

    Correct Answer
    D. Nursing care rounds
    Explanation
    Feedback:
    Nursing care rounds are procedures in which a group of nurses visits select clients individually at each client’s bedside. The primary purposes are to gather information to help plan and evaluate nursing care and to provide the client with an opportunity to discuss care.

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  • 20. 

    A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing?

    • A.

      Data, information, knowledge

    • B.

      Process, documentation, analysis

    • C.

      Research, controls, variables

    • D.

      Hypothesis, nursing, practice

    Correct Answer
    A. Data, information, knowledge
    Explanation
    According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support clients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology (ANA, 2001, p. vii).

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  • 21. 

    A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse?

    • A.

      “I am sorry that you had to suffer this way. The nurse on night duty should be fired.”

    • B.

      “It’s hard to be in bed and ask for help. You ring for a nurse who never seems to help.”

    • C.

      “You seem to be impatient. The nurses work very hard and they do whatever they can.”

    • D.

      “I can see that you are angry. What the nurse did is wrong, and it won’t happen again.”

    Correct Answer
    B. “It’s hard to be in bed and ask for help. You ring for a nurse who never seems to help.”
    Explanation
    The nurse should empathize with the client to perceive how the client is feeling. The nurse shares his or her perception with the client, which makes him comfortable to share his anxieties, fear, and concerns. The first response conveys pity on the client, which is inappropriate. In the third response, the nurse is taking the side of the nursing staff and the client may not like it. The fourth response is nontherapeutic.

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  • 22. 

    A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports?

    • A.

      Pay courtesy calls to staff members before attending the meeting.

    • B.

      Wait for the physicians to arrive before exchanging notes.

    • C.

      Avoid asking questions related to the medical record.

    • D.

      Come prepared with material required to take notes.

    Correct Answer
    D. Come prepared with material required to take notes.
    Explanation
    The nurse should come prepared with material required to take notes during the change-of-shift reports. The nurse should not delay the meeting for change-of-shift report by paying courtesy calls to staff members before attending the meeting. Change-of-shift reports are not conducted in the presence of physicians, thus the nurse does not need to wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

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  • 23. 

    A nurse is manually documenting information related to a client’s condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation?

    • A.

      Erase the incorrect statement and write the correct one.

    • B.

      Cross out the wrong statement in a way that is not readable.

    • C.

      Use correction fluid to obliterate what has been written.

    • D.

      Cross out the incorrect statement with a single line.

    Correct Answer
    D. Cross out the incorrect statement with a single line.
    Explanation
    When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, nor cross out the wrong statement in a way that makes the statement unreadable, nor use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

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  • 24. 

    A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation?

    • A.

      Information is documented in separate forms by each health care personnel.  

    • B.

      It is a unified, cooperative approach for resolving the client’s problems

    • C.

      It is organized at one location according to the client’s health problems.

    • D.

      It is compiled to facilitate communication among health care professionals.

    Correct Answer
    A. Information is documented in separate forms by each health care personnel.  
    Explanation
    Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client’s care. The problem-oriented method of recording demonstrates a unified, cooperative approach to resolving the client’s problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among health care professionals.

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  • 25. 

    A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the first step?

    • A.

      Plan of care

    • B.

      Data, action, and response

    • C.

      Problem selected

    • D.

      Nursing activities during a shift

    Correct Answer
    C. Problem selected
    Explanation
    The SOAP method begins by selecting a problem from a list. PIE (problems, interventions, and evaluation) notes incorporate the plan of care into the progress notes. Focus DAR notes organizes entries by data, action, and response. The narrative notes are used to record relevant client and nursing activities throughout a shift

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  • 26. 

    A nurse is documenting client information using PIE charting. Which information would the nurse expect to document?

    • A.

      Client assessment

    • B.

      Intervention carried out

    • C.

      Written plan of care

    • D.

      Multidisciplinary interventions

    Correct Answer
    B. Intervention carried out
    Explanation
    In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus the nurse would document the intervention carried out. Client assessment is not a part of the PIE notes, because this information is recorded on flow sheets for each shift. Although the PIE system uses a nursing plan-of-care format, there is no written plan of care. The PIE system is not multidisciplinary; it provides a documentation system for nursing only.

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  • 27. 

    What activity in charting will assist most in the avoidance of errors?

    • A.

      Objectivity

    • B.

      Organization

    • C.

      Legibility

    • D.

      Timeliness

    Correct Answer
    D. Timeliness
    Explanation
    Documentation in a timely manner can help avoid errors.

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  • 28. 

    A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident’s response to care. What type of note does this represent?

    • A.

      PIE note

    • B.

      Flow sheet

    • C.

      Narrative note

    • D.

      SOAP note

    Correct Answer
    C. Narrative note
    Explanation
    A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client’s response.

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  • 29. 

    Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that apply.

    • A.

      U (unit)

    • B.

      QD (daily)

    • C.

      NPO (nothing per os)

    • D.

      ML (milliliters)

    • E.

      > (greater than)

    Correct Answer(s)
    A. U (unit)
    B. QD (daily)
    E. > (greater than)
    Explanation
    The words “unit”, “daily”, “greater than” and “less than” should be spelled out. NPO, mL, and mcg are acceptable abbreviations.

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  • 30. 

    Which of the following are examples of incidental disclosures of client health information that are permitted? Select all that apply

    • A.

      A nurse working in a physician’s office puts out a sign-in sheet for incoming clients.

    • B.

      Two nurses are overheard talking about a client through the door of an empty client room.

    • C.

      A nurse places a client chart in a holder on the examining room door with the name facing out.

    • D.

      A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms.

    • E.

      A nurse calls out the name of a client who is seated in the waiting room

    Correct Answer(s)
    A. A nurse working in a physician’s office puts out a sign-in sheet for incoming clients.
    B. Two nurses are overheard talking about a client through the door of an empty client room.
    E. A nurse calls out the name of a client who is seated in the waiting room
    Explanation
    Permitted incidental disclosures of PHI include using sign-in sheets without the reason for visit; the possibility of a conversation being overheard if measures are taken to be private; placing a client chart on the door with the face pages facing inward; placing an x-ray on a light board as long as it is not unattended; calling the name of a waiting patient; and leaving appointment reminders on answering machines (provided only a minimal amount of information is given).

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  • 31. 

    Which of the following are examples of breaches of client confidentiality? Select all that apply.

    • A.

      A nurse discusses a client with a coworker in the elevator.

    • B.

      A nurse shares her computer password with a relative of a client.

    • C.

      A nurse checks the medical record of a client to see who should be called in an emergency.

    • D.

      A nurse updates the employer of a client regarding the client’s return to work.

    • E.

      A nurse uses a computer to document a client’s response to pain medication.

    Correct Answer(s)
    A. A nurse discusses a client with a coworker in the elevator.
    B. A nurse shares her computer password with a relative of a client.
    D. A nurse updates the employer of a client regarding the client’s return to work.
    Explanation
    Nurses may use computers to document client data as long as they are not in a public area, and as long as the computer is shut down following the entries. A nurse can also check the medical record for a relative to call in case of an emergency. All the other examples are violations of client confidentiality.

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  • 32. 

    In which of the following cases should a progress note be written? Select all that apply.

    • A.

      For any nurse–client interaction

    • B.

      When admitting a client

    • C.

      When receiving a client post operatively

    • D.

      When assisting a client with ADLs

    • E.

      When a procedure is performed

    Correct Answer(s)
    B. When admitting a client
    C. When receiving a client post operatively
    E. When a procedure is performed
    Explanation
    A progress note should be written in the following instances: upon admission, transfer to another unit, and discharge; when a procedure is performed; upon receiving a client postoperatively or postprocedure; upon communicating with physicians regarding critical client information (e.g., abnormal lab value result); or for any change in client status.

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  • 33. 

    A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do?

    • A.

      Completely erase or delete the erroneous entry if possible

    • B.

      Use a highlighter to mark the incorrect entry and place initials next to it.

    • C.

      Strike out the entry with a single line, place initials next to it, and write the correct entry.

    • D.

      Black out the erroneous entry with a dark pen or marker

    Correct Answer
    C. Strike out the entry with a single line, place initials next to it, and write the correct entry.
    Explanation
    The nurse should strike out the erroneous entry with a single line and place initials over it. When an error occurs, erasure or use of correction fluid is not permissible. Use of highlighters is not allowed and can draw attention to the erroneous documentation.

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  • 34. 

    The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider?

    • A.

      ISBAR

    • B.

      EMAR

    • C.

      SOAP

    • D.

      CBE

    Correct Answer
    A. ISBAR
    Explanation
    The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.

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  • 35. 

    The nurse is reviewing a client’s chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following?

    • A.

      The physician’s assessment and treatment

    • B.

      Results of laboratory and diagnostic studies

    • C.

      Nursing documentation and plan of care

    • D.

      Information from other members of the health care team

    Correct Answer
    A. The physician’s assessment and treatment
    Explanation
    The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment.

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  • 36. 

    The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations?

    • A.

      When communicating a client’s change in condition to the client’s physician

    • B.

      When providing a change-of-shift report to a colleague

    • C.

      When documenting the care that was provided to a client whose condition recently deteriorated

    • D.

      When reporting to a client’s family member or significant other

    Correct Answer
    A. When communicating a client’s change in condition to the client’s physician
    Explanation
    ISBARR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. ISBARR is considered a framework for communication rather than a format for documentation.

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