NURSE 220-Potter & Perry: Fundamentals of Nursing, 7th Edition Documentation and Informatic test bank

NURSE 220-Potter & Perry: Fundamentals of Nursing, 7th Edition Documentation and Informatic test bank r 26: Documentation and Informatics MULTIPLE 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 colleagues? 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 teaching plan ANS: 4 A change-of-shift report should include instructions given in a teaching plan and the client’s response. This should not include detailed content unless staff members ask for clarification. The nurse should relay to staff significant changes in the way therapies are given, 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 report. 2. Details of the incident are subjectively described. 3. An explanation of the possible cause for the incident is entered. 4. A notation is included in the medical record 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 included. 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 abdominal 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 essential 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 describe 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 example of how to document this type of situation? 1. “2:45 PM—ASA gr X given for temperature of 38.1° C.” 2. “8:30 AM—Client received Percodan (1 tablet) PO an hour before going to radiology.” 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 action and an objective observation. This notation (8:30 AM) is not complete. It does not indicate 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 describes 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-medication 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 error is not correct. It may appear as if the nurse was attempting to hide something or deface 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