Exam 18: Documenting Reporting

The implementation of electronic health records (EHRs) allows the nurse to carry out which actions? Select all that apply.

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

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?

The electronic health record (EHR) is used to document client care. Which purposes are applicable to the EHR? Select all that apply.

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?

Why might a healthcare provider choose narrative charting instead of using forms or checklists?

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

The nurse is administering the 0900 dose of heparin (an anticoagulant) 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT). At 0800, the patient's laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range (excessively elevated). The nurse observes bruising on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding. Which actions would the nurse take? Select all that apply.

A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. Which type of charting is the nurse using?

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?

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

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

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

In performing a handoff report, the nurse should communicate information on which parameters? Select all that apply.

The instructor is teaching the nursing students about electronic health records (EHRs). Which student statement indicates the need for further instruction?

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

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?

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?

At the end of a 12-hour shift, the nurse gives a verbal report to the oncoming nurse. This face-to-face reporting, using the acronym "CUBAN," does which of the following?

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.