Question 1

The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording.In which section would the nurse find the most recent physician orders?
A)Database
B)Problem list
C)Plan of care
D)Progress notes

Accepted Answer

In problem-oriented recording, the plan of care section includes the most recent physician orders as it outlines the strategies for addressing the identified problems.

Question 2

The nurse working in a hospital that utilizes a charting by exception (CBE)documentation system notes that a client did not require care in all of the areas identified on a flow sheet.What action should the nurse take?
A)Leave the areas blank.
B)Leave the areas blank,but then add an extensive explanation in the progress notes section of the chart.
C)Write N/A on the flow sheet in the areas that are not applicable to that client.
D)Make sure this information gets passed along in the shift report.

Accepted Answer

Writing N/A on the flow sheet in the areas that are not applicable to the client is the appropriate action to take in a charting by exception (CBE) system because it indicates that the nurse has assessed that care was not needed in that particular area, rather than leaving it blank which could be interpreted as an oversight or lack of assessment. Adding an extensive explanation in the progress notes section of the chart is not necessary in a CBE system because the flow sheet is designed to capture specific information in a concise manner. Passing the information along in shift report is important, but not the appropriate action for documentation purposes in a CBE system.

Question 3

Before providing care,the nurse reviews the client's pertinent history,daily treatments,diagnostic procedures,allergies,problems,and other information.Which form should the nurse review to learn all of this information?
A)The client's medical record
B)The MAR (medication administration record)
C)The written care plan
D)The Kardex

Accepted Answer

D

Question 4

After classroom discussion regarding confidentiality policies and laws protecting client records,a student asks why it's permissible for them to review and have access to client records in the clinical area.How should the nursing instructor respond?
A)"Confidentiality and privacy laws don't apply to students."
B)"Most students review so many records and charts that they could not possibly remember details from any one of them."
C)"Records are used in educational settings and for learning purposes,but the student is bound to hold all information in strict confidence."
D)"As long as the clinical instructor is in the area,accessing client records is part of the education process."

Accepted Answer

Students may review client records in educational settings for learning purposes, but they are still bound by confidentiality and privacy laws to hold all information in strict confidence.

Answer: D 
 Accessing client records can be a valuable part of the education process, but it should only be done under the supervision of a clinical instructor to ensure that confidentiality and privacy laws are being followed.

Question 5

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.Which problem with documentation might have caused the lack of reimbursement?
A)The client's record contained an incorrect DRG.
B)The client was charged for an ECG.
C)A code cart was opened and the client was charged for medications opened but not used.
D)The physician made a diagnostic mistake.

Accepted Answer

The client's record contained an incorrect DRG (Diagnosis-Related Group), which is used for billing and reimbursement purposes. If the DRG does not accurately reflect the patient's condition and treatment, it can lead to issues with reimbursement.

Question 6

The nurse works at an organization that is installing a new computerized record system.What should the nurse learn that has been implemented to help ensure the security of client records?
A)A firewall to protect the server from unauthorized access
B)One unit password to protect the unit's information
C)Expectation to log off a terminal after using it
D)Expectation to turn the monitor away from view when unattended
E)Requirement to shred all computer-generated worksheets

Accepted Answer

The answer of The nurse works at an organization that...

Question 7

When attempting to locate recent lab results,the new nurse employee notices that each department has a separate section in the client's chart.Which type of documentation system is the nurse using?
A)Source-oriented record
B)Problem-oriented record
C)Case management
D)Focus charting

Accepted Answer

In a source-oriented record, different departments or healthcare providers have separate sections of the client's chart, making it easier to locate information specific to a certain aspect of care.

Question 8

The nurse administered analgesic medications to an assigned client via central line.In which section of PIE charting should the nurse document this information?
A)Plan
B)Intervention
C)Evaluation
D)Progress notes

Accepted Answer

The nurse should document this information in the Intervention section of PIE charting, as it records the actions the nurse has taken to address the client's needs.

Question 9

The nurse makes chronological entries in a client's chart that include documentation about the routine care provided,assessment findings,and client problems during a 12-hour shift.Which type of charting is this nurse completing?
A)Problem-oriented recording
B)Source-oriented recording
C)Narrative charting
D)Plan of care

Accepted Answer

The type of charting the nurse is completing is narrative charting. This involves chronological entries documenting routine care, assessment findings, and client problems. Problem-oriented recording involves a systematic approach to organizing client data around specific problems, whereas source-oriented recording separates information into different sections based on its source. A plan of care outlines the interventions the healthcare team plans to implement for the client.

Question 10

The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack.When utilizing focus charting,in which section should the nurse document this information?
A)Data (D)
B)Action (A)
C)Response (R)
D)Planning (P)

Accepted Answer

The response section of focus charting is used to document the client's response to the treatment or intervention provided. In this case, the client's diminished wheezing after emergency treatment for an acute asthma attack should be documented under the response section.

Question 11

A client in long-term care is scheduled for a review of the assessment and care screening process.Where should the nurse document this information?
A)MDS
B)OBRA
C)CBE
D)Kardex

Accepted Answer

The Minimum Data Set (MDS) is the standard assessment tool used in long-term care facilities to evaluate a resident's needs and develop an individualized care plan. It includes a review of the assessment and care screening process. Therefore, documenting this information in the MDS is the most appropriate choice. OBRA (Omnibus Budget Reconciliation Act) is a federal law that sets minimum standards for nursing homes, but it does not pertain specifically to documentation. CBE (Competency-based education) is a teaching and learning approach that also does not pertain to documentation. Kardex is a term used for a paper-based system used for medication administration and does not pertain to assessment or care planning.

Question 12

A client has specific cultural needs that affect the plan of care.In which part of the client's problem-oriented medical record should the nurse document this information?
A)Database
B)Problem list
C)Plan of care
D)Progress notes

Accepted Answer

The answer of A client has specific cultural needs that...

Question 13

The nurse is documenting client care on flow sheets that identify abnormal assessment findings.Which type of documentation system is the nurse using?
A)Computerized documentation
B)Focus charting
C)SOAP charting
D)Charting by exception

Accepted Answer

Charting by exception is a type of documentation system that focuses on documenting only abnormal assessment findings or significant deviations from expected norms, rather than documenting every detail. This type of documentation can help save time and streamline charting, making it a commonly used system in healthcare settings.

Question 14

A client did not meet the goal of walking unassisted,without assistive devices,by discharge from rehabilitation.The case manager using a critical pathway should identify this outcome as being which of the following?
A)An unattainable goal
B)A variance
C)An error in care planning
D)An error in intervention implementation

Accepted Answer

This outcome would be identified as a variance, which is a deviation from the expected outcome. The case manager would then need to assess the reasons for the variance and determine if any adjustments to the plan of care need to be made. It is not necessarily an unattainable goal, nor is it an error in care planning or intervention implementation without further information.

Question 15

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him,as it's his record.How should the nurse respond to this client's request?
A)"You'll have to ask your doctor for permission to do that."
B)"Actually,the original record is the property of the hospital,but you are welcome to copies of your records."
C)"We'll make sure that all of your records are sent ahead to the rehab hospital,so you don't really have to worry about those details."
D)"There's a new law that protects your records,so you're not going to be able to have access to them."

Accepted Answer

The nurse should explain to the client that while the original record is the property of the hospital, they are entitled to receive copies of their medical records. This ensures that the client has access to their own medical information, while also protecting the hospital's legal ownership of the original record. The nurse should then arrange for copies of the records to be sent to the rehabilitation center, as requested by the client.

Question 16

After completing the client care and documenting it in the progress notes,the nurse realizes that documentation was placed on the wrong medical record.What should the nurse do?
A)Use white-out over the mistake.
B)Take a wide permanent marker and blacken out all the documentation.
C)Put an "X" through the entire page,identify it as an "error," initial,and move on to the correct chart.
D)Draw a single line through the documentation,write "mistaken entry" next to the original entry,and initial it.

Accepted Answer

Drawing a single line through the documentation, writing "mistaken entry" next to the original entry, and initialing it is the appropriate way to correct an error in documentation. This ensures that the mistake is obvious but still allows the accurate information to be read. Using white-out or blacking out the information can be seen as an attempt to hide the mistake, which is not ethical or professional. Simply putting an "X" through the page is not enough to explain the mistake and may even appear careless.

Question 17

When responding to a call light,the nurse finds a client lying on the floor,with the bed linens around the legs.Which chart entry should the nurse document for this finding?
A)Client fell out of bed,but did push the call button for assistance.
B)Client became tangled in the bed linens,then called for assistance after falling out of bed.
C)Recorder responded to client's call light,upon entering the room,found client on floor.
D)Client found on floor,appeared to have fallen out of bed as a result of getting tangled in bed linens.

Accepted Answer

The nurse should document objective observations and facts without making assumptions about what happened.

Question 18

The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format,in which category should the nurse document this statement?
A)Subjective data
B)Objective data
C)Assessment
D)Planning

Accepted Answer

This statement reflects the client's personal feelings and preferences, which qualifies it as subjective data. Subjective data refers to any information provided by the client that relates to their personal experience or feelings, whereas objective data refers to measurable, observable information like vital signs or lab results. Assessment and planning are also not appropriate categories for this statement, as they relate more to the nurse's interpretation of the data and their plans for treatment or interventions.

Question 19

The nurse is teaching medication administration to a client being discharged.Which instruction should the nurse rewrite for this client?
A)Lasix,20 mg,po bid
B)Lasix,20 mg tablet,twice daily
C)Lasix,20 mg by mouth,two times a day a day
D)Lasix,20 mg by mouth 8 AM and 2 PM

Accepted Answer

The instruction "Lasix, 20 mg, po bid" uses medical abbreviations that may not be easily understood by the client. It should be rewritten in plain language to ensure clarity and understanding.

Question 20

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.Which type of form is this hospital utilizing?
A)Standardized care plans
B)Traditional care plans
C)Critical pathways
D)Kardex

Accepted Answer

The hospital is utilizing standardized care plans which include typical nursing diagnoses and standard nursing interventions for specific medical diagnoses.

Quiz 15: Documenting and Reporting

The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording.In which section would the nurse find the most recent physician orders?

The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet.What action should the nurse take?

Before providing care,the nurse reviews the client's pertinent history,daily treatments,diagnostic procedures,allergies,problems,and other information.Which form should the nurse review to learn all of this information?

After classroom discussion regarding confidentiality policies and laws protecting client records,a student asks why it's permissible for them to review and have access to client records in the clinical area.How should the nursing instructor respond?

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.Which problem with documentation might have caused the lack of reimbursement?

The nurse works at an organization that is installing a new computerized record system.What should the nurse learn that has been implemented to help ensure the security of client records?

When attempting to locate recent lab results,the new nurse employee notices that each department has a separate section in the client's chart.Which type of documentation system is the nurse using?

The nurse administered analgesic medications to an assigned client via central line.In which section of PIE charting should the nurse document this information?

The nurse makes chronological entries in a client's chart that include documentation about the routine care provided,assessment findings,and client problems during a 12-hour shift.Which type of charting is this nurse completing?

The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack.When utilizing focus charting,in which section should the nurse document this information?

A client in long-term care is scheduled for a review of the assessment and care screening process.Where should the nurse document this information?

A client has specific cultural needs that affect the plan of care.In which part of the client's problem-oriented medical record should the nurse document this information?

The nurse is documenting client care on flow sheets that identify abnormal assessment findings.Which type of documentation system is the nurse using?

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

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him,as it's his record.How should the nurse respond to this client's request?

After completing the client care and documenting it in the progress notes,the nurse realizes that documentation was placed on the wrong medical record.What should the nurse do?

When responding to a call light,the nurse finds a client lying on the floor,with the bed linens around the legs.Which chart entry should the nurse document for this finding?

The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format,in which category should the nurse document this statement?

The nurse is teaching medication administration to a client being discharged.Which instruction should the nurse rewrite for this client?