Chapter 15: Documenting and Reporting Potter et al: Canadian Fundamentals of Nursing, 6th Edition

Chapter 15: Documenting and Reporting Potter et al: Canadian Fundamentals of Nursing, 6th Edition c. The student nurse shares patient information with a friend. - -A nurse preceptor is supervising a student nurse. Which behaviour by the student nurse will require the nurse preceptor to intervene? a. The student nurse reviews the patient's medical record. b. The student nurse reads the patient's plan of care. c. The student nurse shares patient information with a friend. d. The student nurse documents medication administered to the patient. A report. - -2. A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete? a. The nurse determines the degree to which standards of care are met by reviewing patients' health records. - -Which situation best indicates that the nurse has a good understanding of auditing and monitoring patients' health records? a. The nurse determines the degree to which standards of care are met by reviewing patients' health records. b. The nurse realizes that care not documented in patients' health records still qualifies as care provided. c. The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. d. The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment. d. "Skin pale and cool" - -After providing care, a nurse charts in the patient's record. Which entry should the nurse document? a. "Appears restless when sitting in the chair" b. "Drank adequate amounts of water" c. "Apparently is asleep with eyes closed" After providing care, a nurse charts in the patient's record. Which entry should the nurse document? a. "Appears restless when sitting in the chair" b. "Drank adequate amounts of water" c. "Apparently is asleep with eyes closed" c. "Left abdominal incision 5 cm in length without redness, drainage, or edema." - -A nurse has provided care to a patient. Which entry should the nurse document in the patient's record? a. "Patient seems to be in pain and states, 'I feel uncomfortable.'" b. "Status unchanged, doing well." c. "Left abdominal incision 5 cm in length without redness, drainage, or edema." d. "Patient is hard to care for and refuses all treatments and medications. Family present." The new nurse charts consecutively on every other line. - -A preceptor is