Potter & Perry Ch 26 Documentation Review Questions and Answers

Potter & Perry Ch 26 Documentation Review Questions A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? 1. Avoid rushing when charting an entry 2. Use correction fluid to remove the entry 3. Draw a single line through the statement and initial it 4. Enter only objective and factual information about the patient - ANS 4. Enter only objective and factual information about the patient Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record. A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: 1. Uses SBAR as a format when providing the report 2. Gives a newly ordered medication before entering the order in the patient's medical record 3. Reads the orders back to the health care provider after receiving them and verifies their accuracy 4. Asks the preceptor to listen in on the phone conversation - ANS 2. Gives a newly ordered medication before entering the order in the patient's medical record Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur. As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status?