Question 1

The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order?

Accepted Answer

The correct documentation for a telephone order includes the date and time of the order, the medication prescribed, the route and frequency of administration, the indication (in this case, for pain), and it should be noted as a telephone order (TO) followed by the prescriber's name and the nurse's name and credentials. Option B correctly includes all these elements.

Question 2

Which set of topics makes up a handoff report given in a recommended format?

Accepted Answer

SBAR (Situation-Background-Assessment-Recommendation) is a widely recommended format for handoff reports in healthcare settings, providing a clear, concise way to communicate patient information.

Question 3

The unlicensed assistive personnel (UAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall.

Accepted Answer

Option B is correct because it provides specific information about who found the patient and clearly states the patient's condition (verbalizing left hip pain), which is essential for accurate and accountable documentation.

Question 4

A resident being admitted to a long-term care facility is unable to provide self-care due to dementia and is receiving Medicare funds. At which time must the Resident Assessment and Care Screening be completed?

Accepted Answer

The Resident Assessment and Care Screening must be completed within 2 weeks of admission to a long-term care facility, as part of the requirements for ongoing assessment and care planning for residents, especially those receiving Medicare funds.

Question 5

The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order?

Accepted Answer

Repeating the order to the prescriber ensures accuracy by allowing the prescriber to confirm the order as it was understood by the nurse, reducing the risk of miscommunication.

Question 6

A client is admitted to a long-term care facility. The nurse would use which form to follow federal law?

Accepted Answer

The Minimum Data Set (MDS) is a standardized assessment tool mandated by federal law for use in long-term care facilities to assess the functional capabilities of residents. It ensures that residents receive a comprehensive assessment of their needs.

Question 7

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system?

Accepted Answer

The source-oriented medical record system organizes information according to the source of documentation, leading to potential fragmentation and scattering of related data throughout the chart, making it difficult to track a patient's overall condition and treatment progress efficiently.

Question 8

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; the client is cyanotic (turning blue) with periods of labored breathing. Which action should the nurse take first?

Accepted Answer

The nurse should first look for an advance directive to understand the client's wishes regarding life-sustaining treatment, as the client is in a critical condition.

Question 9

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates correct understanding of the purpose of occurrence reports?

Accepted Answer

Occurrence reports are used within healthcare facilities to document any incident that deviates from standard operations, aiming to track problems and identify areas for quality improvement. They are not specifically required by the FDA for drug errors, by The Joint Commission solely for client falls, nor are they primarily intended to provide legal information for potential lawsuits.

Question 10

Which charting entry would the nurse use for the "A" in SOAP charting?

Accepted Answer

The "A" in SOAP charting stands for "Assessment," which involves the nurse's professional judgment or diagnosis about the patient's condition. "Intractable pain" is an assessment of the patient's condition.

Question 11

A student nurse makes the following comments to the preceptor: "I love getting information from the chart. Everything related to the patient's problem is together and addressed by various members of the healthcare team." The student nurse has been introduced to which type of charting system?

Accepted Answer

The student nurse is describing a Problem-Oriented Medical Record (POMR) system, where all information related to a patient's problem is organized together, allowing various members of the healthcare team to address it collaboratively.

Question 12

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery, a colon resection, for colon cancer. Which integrated plan of care (IPOC) would be priority for the nurse to implement?

Accepted Answer

The priority IPOC for a patient undergoing colon resection for colon cancer is "Postoperative colon resection." This plan addresses the immediate and critical needs following surgery, including pain management, wound care, monitoring for complications, and promoting recovery. While managing hypertension and rheumatoid arthritis remains important, the immediate postoperative care related to the colon resection takes precedence to ensure a successful recovery from surgery.

Question 13

The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates the nurse is following the surgeon's order?

Accepted Answer

OOB in AM means "out of bed in the morning." Assisting the patient out of bed is the action that directly follows the surgeon's order.

Question 14

What is one advantage of problem-intervention-evaluation (PIE) charting?

Accepted Answer

The PIE charting system (Problem-Intervention-Evaluation) is designed to streamline documentation by focusing on specific client problems, the interventions implemented to address those problems, and the evaluation of the effectiveness of those interventions. This approach inherently establishes an ongoing plan of care for the client, as it requires continuous assessment and updating based on the client's response to interventions.

Question 15

At 1000 on 11/14/19, the nurse takes a telephone prescription for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order?

Accepted Answer

The prescriber is typically required to countersign a telephone order within 24 hours.

Question 16

Which aspect is the most beneficial for electronic documentation systems when compared with written documentation systems?

Accepted Answer

Electronic documentation systems improve legibility by eliminating issues related to handwriting, making it easier to read and understand the information.

Question 17

Which instruction by a registered nurse should the student nurse clarify with the clinical instructor about transcribing the provider's orders?

Accepted Answer

The correct instruction should be to use metric units instead of apothecary units, as the metric system is the standard in healthcare for measuring volume, weight, and length due to its accuracy and universal understanding.

Question 18

A patient refuses a dose of medication. How should the nurse document the event?

Accepted Answer

The correct way to document a patient's refusal of medication is to state the fact without adding subjective or judgmental language. Option B accurately and objectively documents the event, specifying the medication and the time without attributing negative characteristics to the patient.

Question 19

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which example would be a major disadvantage of CBE?

Accepted Answer

Charting by exception (CBE) can lead to omissions in client care because it focuses on documenting only deviations from the norm, which might result in missing important information if not properly monitored.

Question 20

Which prescription would the nurse question since it is inconsistent with the standards established by The Joint Commission?

Accepted Answer

The Joint Commission standards recommend avoiding trailing zeros in medication dosages to prevent errors. Therefore, "10.0 mg" should be written as "10 mg".

Quiz 18: Documenting Reporting