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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

Instructions given to the client in a teaching plan

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.

The witnessing nurse completes the report.

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.

0830—Increased IV fluid rate to 100 mL/hr according to protocol.

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

The "P" of PIE

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

Discharge summary form

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.

Draw a straight line through the error and initial it.

8. The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:
1. Uses a pencil to make the entries
2. Uses correction fluid to correct written errors
3. Identifies an error made by the attending physician
4. Dates and signs all of the entries made in the record

Dates and signs all of the entries made in the record

9. What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.
1. "Let me get the Registered Nurse on the phone."
2. "I am unable to take the order at this time. Please call in the morning."
3. "Please repeat the order for me so I can make sure it is written correctly."
4. "Let me have your phone number and I will have the supervisor call you back."

"Let me get the Registered Nurse on the phone."

10. The client developed a slight hematoma on his left forearm. The nurse labels the problem as an infiltrated intravenous (IV) line. The nurse elevates the forearm. The client states, "My arm feels better." What is documented as the "R" in FOCUS charting?
1. "Infiltrated IV line"
2. "My arm feels better"
3. "Elevation of left forearm"
4. "Slight hematoma on left forearm"

"My arm feels better"

11. Which of the following is evaluated as a legally appropriate notation?
1. "Dr. Green made an error in the amount of medication to administer."
2. "Verbalized sharp, stabbing pain along the left side of chest."
3. "Nurse Williams spoke with the client about the surgery."
4. "Client upset about the physical therapy."

"Verbalized sharp, stabbing pain along the left side of chest."

12. To avoid legal risks and possible lack of confidentiality associated with computerized documentation, many programs currently have:
1. Periodic changes in staff passwords
2. Thumbprint identification restrictions
3. All nursing staff uses the same access code
4. Only centralized medical records use the client data

Periodic changes in staff passwords

13. Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy?
1. "Medicare reviews client charts to determine care given."
2. "Good charting results in good Medicare reimbursement."
3. "Our nursing salaries are paid for by the Medicare reimbursement funds."
4. "The hospital is reimbursed for the nursing care documented in the client chart."

"The hospital is reimbursed for the nursing care documented in the client chart."

14. The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment:
1. Secured
2. Accessible
3. Confidential
4. Documented

Confidential

15. Which of the following nursing statements regarding the release of a client's medical record to another institution requires immediate follow-up by the nurse's manager?
1. "I'm pretty sure this will require the client's permission."
2. "Are you sure of the exact policy? Do you know what I should do?"
3. "The client agreed to the consultation, so I'll have the chart sent over."
4. "I think the client will need to give a verbal consent before it can be sent."

"The client agreed to the consultation, so I'll have the chart sent over."

16. Regarding access to client records, the nursing faculty informs the nursing students to be prepared to:
1. Show the unit staff proper student identification
2. Sign a confidentiality agreement when on the unit to preplan
3. Review the medical record only in the presence of unit staff
4. Obtain permission from the client to access his or her medical record

Show the unit staff proper student identification

17. Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care?
1. Notifying the client of the institution's privacy policy
2. Denying nonessential personal access to the client's medical records
3. Acquiring the client's verbal consent to share his or her medical record with essential personnel
4. Requiring that the client sign the Health Insurance Portability and Accountability Act (HIPAA) form

Notifying the client of the institution's privacy policy

18. When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider, this is called a:
1. Referral
2. Consultation
3. Transfer report
4. Multidisciplinary meeting

Referral

19. Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?
1. "Client was angry because breakfast was not to her liking."
2. "Client is depressed; was observed crying while alone in room."
3. "Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."
4. "Client was verbally abusive to staff when approached concerning client's continued attempts to smoke in the bathroom."

"Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."

20. Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data?
1. "Client was angry because breakfast was not to her liking."
2. "Client is depressed; was observed crying while alone in room."
3. "Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."
4. "Client was verbally abusive to staff when approached concerning client's continued attempts to smoke in the bathroom."

"Client is depressed; was observed crying while alone in room."

21. Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation?
1. "The fact that the client refused the prescribed antidepressant medication was noted in his chart."
2. "I provided a detailed description of the dressing change in the client's chart in order to show it was done as prescribed."
3. "The client's wife told me he often develops a rash when he comes into contact with scented soaps, so I noted that in his chart."
4. "I had a long conversation with the client concerning his fears about his upcoming surgery and I mentioned his concerns in my nursing note."

"I provided a detailed description of the dressing change in the client's chart in order to show it was done as prescribed."

22. The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a client's medical record is:
1. James Thicket, NS, WVU
2. J. Jones, NS, Montclair Shores College
3. N.H, SN, Bellfield City Community College
4. Linda Mozden, SN, Fairmont State University

James Thicket, NS, WVU

23. The nurse realizes that the incorrect spelling of terms in the medical record most importantly:
1. Shows a lack of competency
2. Displays little attention to detail
3. Contributes to serious treatment errors
4. Negatively affects the accuracy of the documentation

Contributes to serious treatment errors

24. Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?
1. "His surgery corrected the mobility problem, so I drew a line through it and dated it."
2. "The client's problem list has several resolved problems on it; should I take them off?"
3. "The client no longer has anxiety issues so I highlighted that problem on his problem list."
4. "He doesn't experience any dizziness now that we have his medication regulated, so I've erased that from his problem list."

"He doesn't experience any dizziness now that we have his medication regulated, so I've erased that from his problem list."

25. Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?
1. Risk for injury related to falling due to dizziness
2. Client fell while walking to bathroom unassisted
3. Client continues to report periods of dizziness upon sitting up
4. Educated to the purpose of dangling on the bedside before standing

Risk for injury related to falling due to dizziness

26. Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?
1. Risk for injury related to falling due to dizziness
2. Client fell while walking to bathroom unassisted
3. Client continues to report periods of dizziness upon sitting up
4. Educated to the purpose of dangling on the bedside before standing

Educated to the purpose of dangling on the bedside before standing

1. Nursing documentation should fulfill which of the following criteria? (Select all that apply.)
1. Accurate
2. Inclusive
3. Well organized
4. Show continuity of care
5. Record nursing opinion
6. Identify client outcomes

1. Accurate
2. Inclusive
3. Well organized
4. Show continuity of care
6. Identify client outcomes

2. The nurse realizes that effective nursing documentation encourages: (Select all that apply.)
1. Safe nursing practice
2. Continuity of client care
3. Positive client outcomes
4. Efficient time management
5. Cost-conscious nursing care
6. Effective nurse-client relationships

1. Safe nursing practice
2. Continuity of client care
4. Efficient time management

3. Problem Oriented Medical Record (POMR) method of documentation includes which of the following sections? (Select all that apply.)
1. Database
2. Care plan
3. Evaluations
4. Problem list
5. Interventions
6. Progress notes

1. Database
2. Care plan
4. Problem list
6. Progress notes

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