Chapter 07: Documentation of Nursing Care My Nursing Test Banks

Chapter 07: Documentation of Nursing Care

Test Bank

MULTIPLE CHOICE

1. The nurse with a patient who complains of severe pain documents every 15 minutes about the steps taken to try to relieve the pain (without success). The nurse also documents the time and content of two calls made to the patients physician requesting that the physician examine the patient for unexpected complications. This documentation by the nurse is likely to:

a.

cause the physician to come to the attention of the hospital administration.

b.

be questioned by the nurses supervisor for time inefficiency.

c.

be used against the nurse if a lawsuit results, because it proves the nurse was not able to relieve the pain.

d.

justify insurance reimbursement for an extended duration of hospitalization for the patient.

ANS: D

Documentation of complications or a patients changing condition is used by insurance companies to justify payments for hospitalization. Documentation also serves as evidence of standards of care in a court of law.

DIF: Cognitive Level: Application REF: p. 81 OBJ: Theory #4

TOP: Purposes of Documentation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

2. A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical chart to take, because it is her personal property. An appropriate response would be:

a.

Certainly. This hospital doesnt need to keep it if you are leaving and will not be returning here.

b.

You are entitled to the information in your chart, but the chart is the property of the hospital. I will see about having a copy made for you.

c.

The information in your chart is confidential, and you cannot leave this facility with it.

d.

Because you are leaving against the medical advice of your physician, you may not have the chart.

ANS: B

The chart is the property of the facility, but the patient has a legal right to the information in it even if she is leaving AMA.

DIF: Cognitive Level: Application REF: p. 83 OBJ: Theory #3

TOP: The Medical Record KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

3. A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:

a.

motivated to learn about the health problem of this patient and is appropriately seeking knowledge during his clinical experience.

b.

doing appropriate research about nursing care as long as information is not divulged.

c.

violating the confidentiality of the patients record.

d.

neglecting the assigned patient load and should read the unassigned patients chart only after his assigned work is completed.

ANS: C

A person reading a patients chart who is not involved in the patients care is in violation of confidentiality. Protecting the patients privacy is of prime importance.

DIF: Cognitive Level: Comprehension REF: p. 83 OBJ: Theory #3

TOP: The Medical Record KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

4. A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication. This documentation is:

a.

an example of charting by exception.

b.

evidence of the use of the nursing process.

c.

using the problem-oriented medical record (POMR) format.

d.

usually entered on a flow sheet for treatments and vital signs.

ANS: B

The nursing process is evident in this documentation. Assessment, interventions, and evaluation are all noted.

DIF: Cognitive Level: Analysis REF: p. 83 OBJ: Theory #2

TOP: Methods of Charting KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

5. Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

a.

4 cm reddened area over sacrum. Skin intact, warm, and dry.

b.

Taking fluids poorly, but more than yesterday.

c.

Apparently comfortable all night. Offers no complaints of pain.

d.

Patient says she is still slightly nauseated, would like to try some toast and tea.

ANS: A

Provision of specific objective datasize, location, and characteristics of the patients skinis clear and brief and informative.

DIF: Cognitive Level: Comprehension REF: p. 92 OBJ: Clinical Practice #2

TOP: The Charting Process KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

6. A nurse enters a notation in a patients chart but then discovers that the notation was made in the wrong chart. The nurse correctly:

a.

draws a single line through the notation so that it is still readable and writes mistaken entry, his signature, and the date and time.

b.

removes the page on which the error is written and rewrites the other correct notes.

c.

blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin wrong patient, his signature, and the date and time.

d.

whites out the wrong entry and writes the note in the chart of the correct patient.

ANS: A

When an error is made, no attempt to hide or obliterate the error should be made, because this may be questioned in a court of law.

DIF: Cognitive Level: Application REF: p. 96, Box 7-4

OBJ: Theory #6 TOP: Charting Error Corrections

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

7. A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, I dont want to have you draw any more blood for those useless tests. When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:

a.

Refuses to have blood drawn. Doctor notified.

b.

Refuses to have blood drawn; says tests are useless. Doctor notified.

c.

Doctor notified of failure to draw ordered blood work.

d.

Blood not drawn because tests are no longer desired by patient.

ANS: B

When a patient refuses a treatment, the nurse should document the exact words of the patient regarding why the patient is refusing care.

DIF: Cognitive Level: Application REF: p. 96, Box 7-4

OBJ: Clinical Practice #2 TOP: What to Document

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

8. A clinic nurse is documenting in a patient chart about the pain that brought the patient to seek medical attention. The best description is:

a.

Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch.

b.

Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch.

c.

Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse.

d.

Peri-umbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids.

ANS: D

When charting a sign or symptom, the nurse should include the quality (level 7 to 8), chronology (after lunch, last 3 hours), and aggravating or alleviating factors, as well as associated symptoms.

DIF: Cognitive Level: Application REF: p. 95, Box 7-2

OBJ: Clinical Practice #2 TOP: The Charting Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

9. In a chart for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse charts Subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge. This type of charting is an example of:

a.

charting by exception.

b.

narrative style.

c.

a problem-oriented medical record (POMR).

d.

the case management system.

ANS: C

The POMR focuses on a patient problem or nursing diagnosis and typically uses the SOAP (subjective, objective, assessment, plan) format as shown here.

DIF: Cognitive Level: Application REF: p. 83 OBJ: Theory #4

TOP: Methods of Charting KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

10. In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) charting is that charting by exception:

a.

is well suited to defending nursing actions in court.

b.

contains important data certain to be noted in the narrative sections.

c.

allows staff to learn the system quickly and easily.

d.

highlights abnormal data and patient trends.

ANS: D

Charting by exception enables staff to see notation of changes in a patients condition at a glance.

DIF: Cognitive Level: Comprehension REF: p. 83 OBJ: Theory #4

TOP: Methods of Charting KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

11. If an agency is using computer-assisted charting, the nurse is responsible for:

a.

learning the passwords of the staff nurses and physicians so that they can communicate with one another.

b.

guarding the confidentiality of the patient record by not leaving the patient screen on if he leaves the terminal.

c.

teaching the patient to input information about herself, such as intake and output or symptoms the patient may experience.

d.

choosing whether he will use the computer to help in charting or continue to use traditional paper documentation.

ANS: B

Confidentiality of computer records is as important as that of the paper chart. Nurses must also be protective of their user passwords.

DIF: Cognitive Level: Comprehension REF: p. 90, Box 7-1

OBJ: Theory #4 TOP: Methods of Charting

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: coordinated care

12. A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:

a.

at the end of the shift so that the nurse can give his full attention and time to the patients needs during the shift.

b.

a nursing care plan in the chart before assessing the patient so that the nurse can identify priorities.

c.

at least three times during the shift: at the beginning, in the middle, at the end, and as needed.

d.

an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.

ANS: D

An initial assessment should be performed at the beginning of the shift and promptly documented. It will determine the plan and priorities. Charting should be done as close to the time of occurrence as possible.

DIF: Cognitive Level: Application REF: p. 96, Box 7-4

OBJ: Theory #1 TOP: The Charting Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

13. The nurse uses the flow sheet in patient care documentation primarily:

a.

to track routine assessments, treatments, and frequently given care.

b.

to eliminate written narratives and to save time.

c.

in computer-assisted charting to create visual graphs showing change.

d.

to improve continuity of care and exchange of information among disciplines.

ANS: A

Flow sheets are a time saver but do not eliminate narrative charting. They are used to document information that is routine and that would be lost in a narrative note.

DIF: Cognitive Level: Comprehension REF: p. 83 OBJ: Theory #4

TOP: Flow Sheets KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

14. In a skilled nursing facility, if all of the following are available, the best way for the new nurse to obtain current information about the needs and abilities of his patients would be to use the:

a.

physicians order sheets.

b.

nurses admission history and physical.

c.

nursing Kardex.

d.

most recent nurses notes.

ANS: C

A nursing Kardex is a 1-page summary of the patients diagnosis and current orders, treatments, and care needs.

DIF: Cognitive Level: Knowledge REF: p. 93 OBJ: Clinical Practice #2

TOP: Nursing Kardex KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: coordinated care

15. When the nurse charts in narrative or source-oriented format about the patients condition and the nursing care provided, it is appropriate for him to record:

a.

Patient will go to physical therapy after lunch.

b.

Diabetes in excellent control. Continue with current insulin schedule.

c.

I gave the patient a thorough bath and cut her fingernails.

d.

To x-ray by wheelchair @ 10:30 AM IV infusing in left arm.

ANS: D

Documentation that includes specific information regarding time, method of travel, destination, and current status (that an IV medication is infusing) is a clear example of source-oriented charting.

DIF: Cognitive Level: Application REF: p. 83 OBJ: Theory #4

TOP: Source Oriented Charting KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: coordinated care

16. The nurse understands that a face sheet contains information pertaining to:

a.

serial measurements and observations, such as temperature, pulse, respiration, blood pressure, and weight.

b.

plan of care for the patient, including nursing diagnoses, goals/expected outcomes, and nursing interventions.

c.

written report of the nursing process, record of interventions implemented, and the patients response to them.

d.

patient data, including patients name, address, phone number, insurance company, and admitting diagnosis.

ANS: D

The type of information contained on a face sheet includes patient data, including the patients name, address, phone number, next of kin, hospital identification number, religious preference, place of employment, insurance company, occupation, name of admitting physician, and admitting diagnosis.

DIF: Cognitive Level: Comprehension REF: p. 82, Table 7-1

OBJ: Theory #4 TOP: Documentation Forms

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: coordinated care

17. A nurse understands that the physicians directives for patient care are also referred to as the:

a.

history and physical.

b.

physicians orders.

c.

progress notes.

d.

face sheet.

ANS: B

The physicians directives for patient care are the same as the physicians orders.

DIF: Cognitive Level: Knowledge REF: p. 82, Table 7-1

OBJ: Clinical Practice #4 TOP: The Medical Record

KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

18. A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:

a.

nurse is actively promoting nursing as a profession, and it is important to share information that might encourage others to pursue a nursing career.

b.

actions of the nurse are appropriate since his neighbor is his confidante, and the neighbor has assured him the information provided will not be shared.

c.

nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor.

d.

nurse has not violated the confidentiality of the patient because the patient is terminal; sharing this information will not harm the patient.

ANS: C

As a legal record, the contents of the chart must be kept confidential and can be given out only with the patients written consent because it contains personal information regarding the patient. Only those health professionals caring directly for the patient, or those involved in research or teaching, should have access to the chart. Protecting the privacy of the patient is of prime importance. Patient information is not discussed with others who are not directly involved in the patients care.

DIF: Cognitive Level: Application REF: p. 83 OBJ: Theory #3

TOP: Patient Confidentiality KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

19. The Quality and Safety Education for Nurses (QSEN) project has identified the most important pre-licensing skills for nurses as:

a.

effective communication.

b.

informatics.

c.

familiarity with medical terms.

d.

writing nursing care plans.

ANS: B

The Quality and Safety Education for Nurses (QSEN) project has identified informatics as an important pre-licensing skill.

DIF: Cognitive Level: Knowledge REF: p. 87 OBJ: Theory #4

TOP: Informatics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

20. Advantages of source-oriented or narrative charting include all of the following except that it:

a.

encourages documentation of normal and abnormal findings.

b.

gives information on the patients condition and care in chronological order.

c.

indicates the patients baseline condition for each shift.

d.

includes aspects of all steps of the nursing process.

ANS: A

A disadvantage of source-oriented, or narrative, charting is that it encourages documentation of both normal and abnormal findings, making it difficult to separate pertinent from irrelevant information.

DIF: Cognitive Level: Comprehension REF: pp. 83-84 OBJ: Theory #4

TOP: The Charting Process KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

21. Which examples of documentation would be most informative to transcribe to the patients medical record?

a.

Patient consumed two slices of bread and a cup of coffee at breakfast.

b.

Patient does not appear to be hungry after consuming breakfast.

c.

Patient ate a small amount of bread and drank a little coffee for breakfast.

d.

Patient ate well for breakfast, lunch, and dinner and seems content.

ANS: A

Use of the words appears to or seems in phrases such as appears to be resting should be avoided. Chart the behavior; the patient either is or is not resting. Words that have ambiguous meanings and slang should not be used in charting. For example, how much is a little, a small amount, or a large amount? What do phrases such as ate well and taking fluids poorly mean? Although such words give a general idea of what is meant, they are not specific.

DIF: Cognitive Level: Application REF: p. 92 OBJ: Theory #4

TOP: Source Oriented Charting KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: coordinated care

COMPLETION

22. Charting that follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses progress notes is _______ charting.

ANS:

PIE

problem identification, intervention, and evaluation

The nurse needs to be able to define PIE charting.

DIF: Cognitive Level: Knowledge REF: p. 86 OBJ: Theory #2

TOP: Documentation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: coordinated care

23. Health care professionals assigned to a patient require access to the chart to review information and to document care given. All contents of the chart must be kept ________. The contents of the chart should not be discussed with persons who are not involved in the care of the patient.

ANS:

confidential

The nurse needs to be able to identify what confidentiality entails.

DIF: Cognitive Level: Knowledge REF: p. 83 OBJ: Theory #3

TOP: Confidentiality KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

24. The nurse explains that should a patient return to the hospital for treatment within _______ years, the medical chart can be retrieved from medical records for review.

ANS:

10

ten

Medical records are kept in the health information department of a hospital for a period of 10 years.

DIF: Cognitive Level: Knowledge REF: p. 83 OBJ: Theory #3

TOP: Storage of Medical Records KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: coordinated care

25. When using a case management system of charting a(n) __________, an unexpected event in the patients condition is documented on the back of the pathway sheets.

ANS:

variance

A variance is an unexpected event in the patients course of care. An example would be a healing wound that was complicated by an infection.

DIF: Cognitive Level: Knowledge REF: p. 83, Figure 7-10

OBJ: Theory #4 TOP: Variances KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

MULTIPLE RESPONSE

26. Advantages of the problem-oriented medical record (POMR) are that this method of charting: (Select all that apply.)

a.

promotes the problem-solving approach.

b.

formats charting into chronological order.

c.

makes tracking trends in patient care easy.

d.

allows for easy auditing of patient records to evaluate staff performance.

e.

reinforces application of the nursing process.

ANS: A, D, E

POMR promotes problem solving with the reinforcement of the nursing process. This method allows for easy auditing of patient records.

DIF: Cognitive Level: Comprehension REF: p. 85 OBJ: Theory #4

TOP: Problem Oriented Charting KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

27. The method of computer-assisted charting: (Select all that apply.)

a.

improves communication between departments.

b.

is less costly to educate personnel to the method.

c.

speeds reimbursement for services.

d.

allows electronic records to be retrieved more quickly.

e.

allows entries to be made at point of care.

ANS: A, C, D, E

Computerized charting improves communication between departments, speeds reimbursement for services and retrieval of records, and allows entries to be made quickly at the point of care. It is more expensive to educate personnel in the use of computers than in other forms of documentation.

DIF: Cognitive Level: Knowledge REF: pp. 89-90 OBJ: Theory #4

TOP: Documentation KEY: Nursing Process Step: Implementation

MSC: NCLEX: N/A

28. Helpful cultural information the nurse should include on the admission note is: (Select all that apply.)

a.

primary language spoken.

b.

number of children in the immediate household.

c.

beliefs about causality of illness.

d.

level of English literacy.

e.

dietary concerns.

ANS: A, C, D, E

Information relative to primary language, beliefs about cause of illness, level of English literacy, and dietary concerns are helpful items to include on the admission note.

DIF: Cognitive Level: Comprehension REF: p. 91 OBJ: Theory #1

TOP: Cultural Information KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe Effective Care Environment: coordinated care

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