Documenting, Reporting, Conferring, And Using Informatics

36 Questions | Total Attempts: 214

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Documenting, Reporting, Conferring, And Using Informatics

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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

  • 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

  • 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

  • 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”

  • 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

  • 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.”

  • 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.”

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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.

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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.”

  • 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.

  • 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.

  • 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.

  • 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

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