Chapter 15 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 15

Question 1

Type: MCSA

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with them, since its his record. The nurse responds correctly by saying:

1. Youll have to ask your doctor for permission to do that.

2. Actually, the original record is the property of the hospital, but you are welcome to copies of your records.

3. Well make sure that all of your records are sent ahead to the rehab hospital, so you dont really have to worry about those details.

4. Theres a new law that protects your records, so youre not going to be able to have access to them.

Correct Answer: 2

Rationale 1: The doctors permission is not a requirement for the release of a clients medical record.

Rationale 2: Although the clients record is protected legally as private, access to the record is restricted to health professionals involved in the clients care. The institution or agency is the rightful owner of the clients record, but the client has the right to access all information contained within his own record and to have a copy of the original record. The hospital has the right to charge a fee for the copying costs. The Health Insurance Portability and Accountability Act (HIPAA) is a law enacted to protect health information and maintain confidentiality of client records.

Rationale 3: The client does have a legal right concerning his medical record so this option doesnt adequately address his question.

Rationale 4: This option is not correct, the client does have a legal right to access his medical records.

Global Rationale: Page Reference: 251

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 List the measures used to maintain confidentiality and security of computerized client records.

Question 2

Type: MCSA

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why its permissible for them to review and have access to client records in the clinical area. The nurse educator responds correctly by stating that:

1. Confidentiality and privacy laws dont apply to students.

2. Most students review so many records and charts that they could not possibly remember details from any one of them.

3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence.

4. As long as the clinical instructor is in the area, accessing client records is part of the education process.

Correct Answer: 3

Rationale 1: This option is not correct, the laws do apply to students.

Rationale 2: While this may or may not be a true statement it is not an appropriate response to the students question.

Rationale 3: For purposes of education and research, most agencies allow students and graduate health professionals access to client records. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health professional to protect the clients privacy by not using a name or any statements in the notations that would identify the client.

Rationale 4: While this is true it should not imply that the laws of confidentiality dont apply to students.

Global Rationale: Page Reference: 251

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 List the measures used to maintain confidentiality and security of computerized client records.

Question 3

Type: MCSA

A nurse is employed as an MIS (medical information system) trainer at a hospital where a new computerized record system is being installed. According to the Security Rule of HIPAA, which of the following should be implemented to help ensure the security of client records?

1. Install a firewall to protect the server from unauthorized access.

2. Give each unit the same password to protect the units information.

3. Log off a terminal after using it.

4. Make sure the monitor is turned away from view when unattended.

5. Shred all computer-generated worksheets.

Correct Answer: 1,3,5

Rationale 1: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include the installation of a firewall to protect from unauthorized access.

Rationale 2: Guidelines for confidentiality and security of computerized records include assignment of a personal password to enter and log off computer files. The password should not be shared with anyone, including other team members.

Rationale 3: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information That includes never leaving a monitor unattended after logging on.

Rationale 4: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information requires that a one should never leave a monitor unattended after logging on. Turning the monitor away from view is not a sufficient safeguard.

Rationale 5: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include shredding all confidential information.

Global Rationale: Page Reference: 251

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 List the measures used to maintain confidentiality and security of computerized client records.

Question 4

Type: MCSA

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. A problem in documentation that may have caused the lack of reimbursement would be which of the following?

1. The clients record contained an incorrect DRG.

2. The client was charged for an ECG.

3. A code cart was opened and the client was charged for medications opened but not used.

4. The physician made a diagnostic mistake.

Correct Answer: 1

Rationale 1: Documentation helps a facility receive reimbursement from the federal government. The clients clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given. Codable diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses.

Rationale 2: This would not necessarily result in the problem related to reimbursement since it is a reasonable diagnostic test to perform in this situation.

Rationale 3: This would not necessarily result in the problem related to reimbursement.

Rationale 4: This would not necessarily result in the problem related to reimbursement.

Global Rationale: Page Reference: 252

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Discuss purposes for client records.

Question 5

Type: MCSA

When attempting to locate recent lab results, the student notices that each department has a separate section in the clients chart. This type of documentation system is called which of the following?

1. Source-oriented record

2. Problem-oriented record

3. Case management

4. Focus charting

Correct Answer: 1

Rationale 1: The traditional client record is a source-oriented record in which each person or department makes notations in a separate section or sections of the clients chart.

Rationale 2: In the problem-oriented medical record, the data are arranged according to the problems the client has rather than the source of the information.

Rationale 3: Case management uses a multidisciplinary approach to documenting client care, called critical pathways.

Rationale 4: Focus charting is intended to make the client and client concerns the focus of care, utilizing a three-column format.

Global Rationale: Page Reference: 252

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model.

Question 6

Type: MCSA

A nurse makes an chronological entries in a clients chart that includes documentation about the routine care, assessment findings, and client problems provided during a 12 hour shift. This is an example of :

1. Problem-oriented recording

2. Source-oriented recording

3. Narrative charting

4. Plan of care

Correct Answer: 3

Rationale 1: Problem-oriented recording is arranging the data according to the problem the client has.

Rationale 2: Source-oriented recording is arranged in separate sections for each department that contributes to the clients care. Plan of care is part of the problem-oriented medical record.

Rationale 3: Narrative charting is a traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used.

Rationale 4: Plan of care is part of the problem-oriented medical record.

Global Rationale: Page Reference: 252

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model.

Question 7

Type: MCSA

A nurse is reviewing a clients chart in a facility that utilizes problem-oriented recording. In looking for the most recent physician orders, the nurse should look in which section?

1. Database

2. Problem list

3. Plan of care

4. Progress notes

Correct Answer: 3

Rationale 1: The database consists of all known information about the client upon admission.

Rationale 2: The problem list includes those identified problems, listed in the order in which they are identified.

Rationale 3: The initial list of orders or plan of care is made with reference to the clients active problems in this type of charting. Physicians write physician orders or the medical care plan.

Rationale 4: Progress notes are chart entries made by all health professionals involved in the clients care.

Global Rationale: Page Reference: 254

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model.

Question 8

Type: MCSA

A client has specific cultural needs in regard to the plan of care. This information would be found in which of the following?

1. Database

2. Problem list

3. Plan of care

4. Progress notes

Correct Answer: 2

Rationale 1: The database includes information about the client when admitted to the facility.

Rationale 2: The problem list is derived from the database and is usually kept at the front of the chart. The problem list serves as an index to the numbered entries in the progress notes. All caregivers contribute to the problem list, which includes the clients physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs.

Rationale 3: The plan of care is made with reference to the active problems.

Rationale 4: Progress notes are chart entries made by all health professionals involved in a clients care.

Global Rationale: Page Reference: 254

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Explain how various forms in the client record (e.g., critical pathways care plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating).

Question 9

Type: MCSA

The client states: I really dont want anyone to visit me who has not been cleared by me first. If utilizing SOAP format, this statement would be documented under which category?

1. Subjective data

2. Objective data

3. Assessment

4. Planning

Correct Answer: 1

Rationale 1: Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the clients words; otherwise, they are summarized.

Rationale 2: Objective data consist of information that is measured or observed.

Rationale 3: Assessment is the interpretation or conclusion drawn about the subjective and objective data. This is the area where the problems are documented initially. Then the clients condition and level of progress are subsequently described.

Rationale 4: Planning is the care designed to resolve the problem.

Global Rationale: Page Reference: 254

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model.

Question 10

Type: MCSA

The nurse administered analgesic medications to an assigned client via central line. This information should be documented in which section if using PIE charting?

1. Plan

2. Intervention

3. Evaluation

4. Progress notes

Correct Answer: 2

Rationale 1: The problem statement is labeled P and referred to by number.

Rationale 2: The interventions employed to manage the problem are labeled I and numbered according to the problem.

Rationale 3: The E is evaluation of the effectiveness of the intervention and is also labeled and numbered according to the problem..

Rationale 4: Progress notes are not part of the identified labels of PIE charting.

Global Rationale: Page Reference: 256

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model.

Question 11

Type: MCSA

Flow sheets and abnormal assessment finds are components of:

1. Computerized documentation

2. Focus charting

3. SOAP charting

4. Charting by exception

Correct Answer: 4

Rationale 1: Computerized documentation is a way to manage the volume of information required in a clients chart, and different systems may include a variety of setups and programs.

Rationale 2: Focus charting is organized into data, action, and response sections, referred to as DAR.

Rationale 3: SOAP charting is a way to organize data and information in the clients record: S = subjective data; O = objective data; A = assessment; P = plan.

Rationale 4: Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE.

Global Rationale: Page Reference: 257

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model.

Question 12

Type: MCSA

A nurse works in a hospital that utilizes a charting by exception documentation system. When documenting care and assessments using the charting by exception system, the nurse may not address all of the sections on a clients flow sheet, especially if the client did not require this particular care. In order for the nurse to identify that these areas were addressed, but no care was needed, the best action is to:

1. Leave them blank.

2. Leave them blank, but then add an extensive explanation in the progress notes section of the chart.

3. Write N/A on the flow sheet in the areas that are not applicable to that client.

4. Make sure this information gets passed along in the shift report.

Correct Answer: 3

Rationale 1: It is never a good idea to leave blanks in any charting area since it implies that the area was ignored.

Rationale 2: It is never a good idea to leave blanks in any charting area. Adding the information in the progress notes is not an appropriate use of that section.

Rationale 3: Many nurses are uncomfortable with the CBE system and believe that if something was not charted, it was not done. A suggestion to address this would be to write N/A on the flow sheets where the items are not applicable to the client, and not leave the spaces blank. This would avoid the possible assumption that the assessment or intervention was not done by the nurse.

Rationale 4: Passing information along in the report is a good way to ensure continuity of care for clients, but this would only be an oral report, not written documentation.

Global Rationale: Page Reference: 257

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model.

Question 13

Type: MCSA

A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway would identify this as which of the following?

1. An unattainable goal

2. A variance

3. An error in care planning

4. An error in intervention implementation

Correct Answer: 2

Rationale 1: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is not referred to as an unattainable goal since a change in the clients care plan may result in success.

Rationale 2: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is called a variance. Variances are deviations to what is planned in the critical pathwayunexpected occurrences that affect the planned care or the clients response to care.

Rationale 3: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is not referred to as an error in care planning since the success of a goal is dependent on specific interventions and individual client response.

Rationale 4: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is not referred to as an error in implementation since the success of a goal is not solely dependent on the implementation of a single intervention.

Global Rationale: Page Reference: 260

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 04 Explain how various forms in the client record (e.g., critical pathways care plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating).

Question 14

Type: MCSA

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. This hospital is utilizing which of the following?

1. Standardized care plans

2. Traditional care plans

3. Critical pathways

4. Kardex

Correct Answer: 1

Rationale 1: Standardized care plans were developed to save documentation time. These plans may be based on an institutions standards of practice, thereby helping to provide a high quality of nursing care. Standardized care plans are usually individualized to address each clients specific needs.

Rationale 2: Traditional care plans are written for each client, are specific, and are individualized for that client.

Rationale 3: Critical pathways are used in case management, involving a multidisciplinary approach to planning and documenting client care.

Rationale 4: The Kardex is a concise method of organizing and recording data about a client-making information quickly accessible for all health professionals.

Global Rationale: Page Reference: 261

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Explain how various forms in the client record (e.g., critical pathways care plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating).

Question 15

Type: MCSA

Before the clinical experience begins, the student must be aware of the clients pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information in order to provide the most appropriate care during the shift. In order to help the student save time in researching all of this information, the review should begin with the:

1. The clients medical record

2. The MAR (medication administration record)

3. The written care plan

4. The Kardex

Correct Answer: 4

Rationale 1: The medical record contains this type of information but the complete chart is lengthy and would take the student more time to review.

Rationale 2: The MAR includes only those medications that are prescribed or scheduled to be administered during the clients stay. It would not include other information like diagnostic tests, daily cares, and so on.

Rationale 3: The written care plan may be utilized but there is another more effective option available.

Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible to all health professionals. The system is on either an index-type file or a computer-generated form. Information is usually organized into sections: client history/information, list of medications, IV fluids, daily treatments and procedures, diagnostic procedures, allergies, how the clients physical needs are met (type of diet, bathing needs, etc.), and a problem list with stated goals.

Global Rationale: Page Reference: 261

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Explain how various forms in the client record (e.g., critical pathways care plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating).

Question 16

Type: MCSA

The nurse is doing teaching regarding medication administration for a client who is being discharged. Which of the following instructions should be rewritten for this client?

1. Lasix, 20 mg, po bid

2. Lasix, 20 mg tablet, twice daily

3. Lasix, 20 mg by mouth, two times a day a day

4. Lasix, 20 mg by mouth 8 AM and 2 PM

Correct Answer: 1

Rationale 1: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in laymans terms, and use of medical abbreviations should be avoided. Twice a day should be written out, not abbreviated as bid.

Rationale 2: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in laymans terms, and use of medical abbreviations should be avoided. Twice a day should be written out, not abbreviated as bid.

Rationale 3: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in laymans terms, and use of medical abbreviations should be avoided. Twice a day should be written out, not abbreviated as bid.

Rationale 4: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in laymans terms, and use of medical abbreviations should be avoided. Twice a day should be written out, not abbreviated as bid.

Global Rationale: Page Reference: 262

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Compare and contrast the documentation needed for clients in acute care, long-term care, and home health care settings.

Question 17

Type: MCSA

A client in long-term care is scheduled for a review of the assessment and care screening process. This assessment will be documented in which of the following?

1. MDS

2. OBRA

3. CBE

4. Kardex

Correct Answer: 1

Rationale 1: The Minimum Data Set (MDS) for assessment and care screening must be performed within 4 days of a clients admission to a long-term care facility and reviewed every 3 months. Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987.

Rationale 2: Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987.

Rationale 3: \ CBE stands for charting by exception and is not the form of documentation used for this type of assessment.

Rationale 4: Kardex is a system of organizing client information so it can be accessed quickly. It is usually used in the acute care area.

Global Rationale: Page Reference: 262-263

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Compare and contrast the documentation needed for clients in acute care, long-term care, and home health care settings.

Question 18

Type: MCSA

The nurse responds to a clients call light. When entering the room, the nurse sees that the client is lying on the floor, with the bed linens around the legs. The most correctly written chart entry is:

1. Client fell out of bed, but did push the call button for assistance.

2. Client became tangled in the bed linens, then called for assistance after falling out of bed.

3. Recorder responded to clients call light, upon entering the room, found client on floor.

4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.

Correct Answer: 3

Rationale 1: It should never be assumed that the client fell out of bed.

Rationale 2: It should never be assumed that the client fell out of bed, became tangled in bedding, or anything else.

Rationale 3: Accurate notations consist of facts or observations rather than opinions or interpretations. The client was found on the floor, and the call light was activated. Those are the only things known until the nurse learns further information from questioning the client.

Rationale 4: It should never be assumed that the client became tangled in bedding, or anything else.

Global Rationale: Page Reference: 267

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Discuss guidelines for effective recording that meet legal and ethical standards.
08 Identify essential guidelines for reporting client data.

Question 19

Type: MCSA

After completing the client care and documenting it in the progress notes, the nursing student discovered he had written in the wrong chart. The correct action is to:

1. Use white-out over the mistake.

2. Take a wide permanent marker and blacken out all the documentation.

3. Put an X through the entire page, identify it as an error, initial, and move on to the correct chart.

4. Draw a single line through the documentation, write mistaken entry next to the original entry, and initial it.

Correct Answer: 4

Rationale 1: Erasure, blotting out, or correction fluid should not be used.

Rationale 2: Erasure, blotting out, or correction fluid should not be used.

Rationale 3: When a mistake is recorded The correction applies to only the erroneous information not the entire page.

Rationale 4: When a mistake is recorded, a line should be drawn through it and the words mistaken entry written above or next to the original entry, then initial or signaturewhichever is agency policy. The original entry must remain visible.

Global Rationale: Page Reference: 266

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Discuss guidelines for effective recording that meet legal and ethical standards.

Question 20

Type: MCMA

A nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. Which of the following would the nurse select as positive aspects of implementing this type of system?

Standard Text: Select all that apply.

1. The system is relatively inexpensive to maintain.

2. Bedside terminals eliminate worksheets and note taking.

3. The system links to various sources of client information.

4. The system better protects client privacy.

5. Information is legible.

6. Results, requests, and client information can be sent and received quickly.

Correct Answer: 2,3,5,6

Rationale 1: This system is not inexpensive to maintain.

Rationale 2: This is considered a positive aspect of this type of charting.

Rationale 3: This is considered a positive aspect of this type of charting.

Rationale 4: The effectiveness of this system to protect a clients privacy is dependent upon the personnel using it.

Rationale 5: This is considered a positive aspect of this type of charting.

Rationale 6: This is considered a positive aspect of this type of charting.

Global Rationale: Page Reference: 260

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 01 List the measures used to maintain confidentiality and security of computerized client records.

Question 21

Type: MCSA

The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack. When utilizing focus charting, this information would be included in the section identified as:

1. Data (D).

2. Action (A).

3. Response (R).

4. Planning (P).

Correct Answer: 3

Rationale 1: The data (D) section reflects the assessment phase of the nursing process, and consists of observations of client status and behaviors, including data from flow sheets.

Rationale 2: The action (A) category reflects planning and implementation, and includes immediate and future nursing action.

Rationale 3: The response (R) category reflects the evaluation phase of the nursing process, and describes the clients response to any nursing and medical care.

Rationale 4: Planning is a subcategory of Action (A).

Global Rationale: Page Reference: 256

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model.
08 Identify essential guidelines for reporting client data.

Question 22

Type: MCMA

Evidence that a nurse adheres to practice guidelines that result in documentation that meets legal and ethical standards is shown when:

Standard Text: Select all that apply.

1. Charting the clients response to pain medication taken.

2. Describing the client as appearing to be comfortable.

3. Leaving sufficient charting space for the previous shift to chart client teaching.

4. Documenting that the client reports, Im so afraid of tomorrows surgery.

5. Making a late entry regarding a clients request for pain medication.

Correct Answer: 1,4,5

Rationale 1: Documentation guidelines include charting a change in a clients condition and showing that follow-up actions were taken.

Rationale 2: Documentation guidelines include not using vague terms (e.g., appears to be comfortable).

Rationale 3: Documentation guidelines include not leaving a blank space for a colleague to chart later.

Rationale 4: Documentation guidelines include recording the clients actual words by putting quotation marks around the words.

Rationale 5: Documentation guidelines include the idea that a late entry is better than no entry.

Global Rationale: Page Reference: 263

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 06 Discuss guidelines for effective recording that meet legal and ethical standards.

Question 23

Type: MCMA

The nurse shows an understanding of the importance of avoiding potentially confusing abbreviations when:

Standard Text: Select all that apply.

1. Documenting vital signs as TPR.

2. Charting that the drsg was dry and intact.

3. Transcribing a verbal order as Carbamazepine 12 mg/ml IV push daily.

4. Documenting Client consistently requesting IM MS for pain well before prescribed time.

5. Charting, Client to be ambulated q.i.d.

Correct Answer: 1,2,5

Rationale 1: This is a commonly used and accepted abbreviation for temperature, pulse, and respirations (vital signs).

Rationale 2: This is a commonly used and accepted abbreviation for a treatment dressing.

Rationale 3: Mg (micrograms) is not an accepted abbreviation, since it can be confused with mg (milligrams), resulting in a one thousandfold overdose.

Rationale 4: MS is not an accepted abbreviation for morphine sulfate, since it can be confused with magnesium sulfate, resulting in a drug error.

Rationale 5: This is a commonly used and accepted abbreviation for four times a day.

Global Rationale: Page Reference: 264

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 07 Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form of clinical documentation.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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