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Chapter 026

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 26: Documentation and Informatics MULTIPLE CHOICE 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 A
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 2: !o umentation and #nformati s$%T#PE C'(#CE 1.The nurse is preparing the information that will be provided to the staff on the next shift. Which of the following should the nurse include in the inter-shift report to nursing colleagues?1.Audit of client care procedures2.The client’s diagnostic-related group.All routine care procedures re!uired b the client#.$nstructions given to the client in a teaching planA%&'#A change-of-shift report should include instructions given in a teaching plan and the client’s response. This should not include detailed content unless staff members as( for clarification. The nurse should rela to staff significant changes in the wa therapies are given) but should not describe basic steps of a procedure. The client’s diagnosis-related group is not essential bac(ground information to be shared in an inter-shift report. The nurse should not review all routine care procedures or tas(s.*$+'A,+'/0'omprehensionT/3'%ursing 3rocess' valuation4&'%567 test plan designation' &afe) ffective are nvironment2.An incident report is to be completed because the client climbed over the side rails and fell to the floor. The correct reporting of an incident involves which of the following?1.The witnessing nurse completes the report.2.*etails of the incident are sub8ectivel described..An explanation of the possible cause for the incident is entered.#.A notation is included in the medical record that an incident report was prepared.A%&'1The nurse who witnessed the incident is the one who completes the report. *etails of the incident should be ob8ectivel described. An explanation of the possible cause is not included. The se!uence of events is described ob8ectivel . A notation is not included in the medical record that an incident report was written.*$+'A,+'#9/0'omprehensionT/3'%ursing 3rocess' valuation4&'%567 test plan designation' &afe) ffective are nvironment.Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?1.129:lient’s vital signs ta(en.2.9;99:lient dran( ade!uate amount of fluids. 4osb items and derived items < 299) 299= b 4osb ) $nc.) an affiliate of lsevier $nc.  Test 0an( .999:*emerol given for lower abdominal pain.#.9>9:$ncreased $ fluid rate to 199 m5@hr according to protocol.A%&'#$nformation within a recorded entr needs to be complete) containing appropriate and essential information. This notation 9>9B provides the time and action ta(en b the nurse including the reason for doing so. This entr 129B does not indicate what the vitalsigns were. This entr 9;99B does not provide the specific amount the client dran(. &tating Cade!uateD is sub8ective) not ob8ective. This notation 999B does not have the client describe his or her pain or rate it according to a pain scale for comparison later. $t also does not indicate whether the client’s pain was in the lower left or lower right !uadrant) or both.*$+'A,+'>/0'omprehensionT/3'%ursing 3rocess' valuation4&'%567 test plan designation' &afe) ffective are nvironment#.The nurse ma(es a late entr in a client’s record. Which of the following is the best example of how to document this t pe of situation?1.C2'#= 34  :A&A gr 6 given for temperature of >.1E .D2.C>'9 A4  :lient received 3ercodan 1 tabletB 3/ an hour before going to radiolog .D.C12'1= 34  :$ gave the client morphine 19 mg $4 at 11'19 A4  but did not document it then.D#.C>'9 34  :Abdominal dressing change at ;'9 34. %o s@s of infection) and woundedges approximating well.DA%&'1This is the best example of a late entr . The time 2'#= 34 B is indicated along with the action and an ob8ective observation. This notation >'9 A4 B is not complete. $t does not indicate wh the 3ercodan was given. What was the client’s level of pain? Where was the pain located? The nurse does not need to document about herselfF onl the client. $n this option 12'1= 34 B) the nurse does not indicate wh the morphine was given client’s levelof pain? location of pain?B. This entr >'9 34 B is not complete. $t does not state the siGe of the wound) t pe of dressing used) or the client’s tolerance of the procedure.*$+'A,+'>/0'omprehensionT/3'%ursing 3rocess' valuation4&'%567 test plan designation' &afe) ffective are nvironment=.The following statement' CHpon exertion) the client is wheeGing and experiencing some d spnea)D is an example of'1.The C3D of 3$ 2.+/H& documentation.The C,D in *A, documentation #.The C&D in &/A3 documentationA%&'1 4osb items and derived items < 299) 299= b 4osb ) $nc.) an affiliate of lsevier $nc. 2I-2  Test 0an( These data are examples of the C3D of 3$ because the describe the problem. +/H& charting does not concentrate on onl problems. $t is structured according to a client’s concerns. The C,D in *A, documentation is the response of the client. This situation describes the client’s problem) not the client’s response. The C&D in &/A3 documentationrepresents sub8ective data verbaliGations of the clientB.*$+'A,+'1/0'omprehensionT/3'%ursing 3rocess' valuation4&'%567 test plan designation' &afe) ffective are nvironmentI.To locate the recording of a nurse’s description of the teaching provided to the client on  performance of self-medication administration) one would loo( in anB'1.Jardex2.$ncident report.%ursing histor form#.*ischarge summar formA%&'#A nurse’s description of the teaching provided to the client on performance of self-medication administration is recorded in the discharge summar form. A Jardex is a written form that contains basic client information. A Jardex contains an activit and treatment section and a nursing care plan section that organiGes information for !uic( reference as nurses give change-of-shift report. $t does not include a description of teaching that was provided to the client. An incident report is an event that is not consistent with the routine operation of a health care unit or routine care of a client e.g.) a client fallsB. A nursing histor form guides the nurse through a complete assessment to identif relevant nursing diagnoses or problems. $t provides baseline data about the client.*$+'A,+';->/0'omprehensionT/3'%ursing 3rocess' valuation4&'%567 test plan designation' &afe) ffective are nvironment;.The nurse has made an error and is documenting such on the client’s record and notes. The action that the nurse should ta(e is to'1.*raw a straight line through the error and initial it.2.rase the error and write over the material in the same spot..Hse a dar( color mar(er to cover the error and continue immediatel after that  point.#.+ootnote the error at the bottom of the page.A%&'1 4osb items and derived items < 299) 299= b 4osb ) $nc.) an affiliate of lsevier $nc. 2I-  Test 0an( $f a nurse has made an error in documentation) the nurse should draw a single line through the error) write the word error   above it) and sign his or her name or initials. Then record the note correctl . The nurse should not erase) appl correction fluid) or scratch out errors made while recording because charting becomes illegible. Also) entries should onl be made in in( so the cannot be erased. Hsing a dar( color mar(er to cover the error is not correct. $t ma appear as if the nurse was attempting to hide something or deface the record. +ootnotes are not used in nursing documentation.*$+'A,+'>>->/0'omprehensionT/3'%ursing 3rocess' valuation4&'%567 test plan designation' &afe) ffective are nvironment>.The new staff nurse is having her documentation evaluated b the charge nurse. /n review of her charting) the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse'1.Hses a pencil to ma(e the entries2.Hses correction fluid to correct written errors.$dentifies an error made b the attending ph sician#.*ates and signs all of the entries made in the recordA%&'#ach entr should begin with the time and end with the signature and title of the person recording the entr . All entries should be recorded legibl and in blac( in( because pencilcan be erased. The nurse should never erase entries) never use correction fluid) or never use a pencil. The use of correction fluid could ma(e the charting become illegible and it ma appear as if the nurse were attempting to hide something or to deface the record. $f the ph sician made an error) the nurse should not document it in the client’s chart. $t should be documented in an incident report.*$+'A,+'>/0'omprehensionT/3'%ursing 3rocess' valuation4&'%567 test plan designation' &afe) ffective are nvironment.What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The ph sician calls to leave orders late at night for one of his clients. 1.C5et me get the ,egistered %urse on the phone.D2.C$ am unable to ta(e the order at this time. 3lease call in the morning.D.C3lease repeat the order for me so $ can ma(e sure it is written correctl .D#.C5et me have our phone number and $ will have the supervisor call ou bac(.DA%&'1 4osb items and derived items < 299) 299= b 4osb ) $nc.) an affiliate of lsevier $nc. 2I-#

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