Exam 18: Documenting Reporting

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?

Which statements by the student nurse indicates a correct understanding of the nursing Kardex? Select all that apply.

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

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

A medical provider has prescribed milk of magnesia (magnesium hydroxide) 30 mL, PO bid. What does bid mean?

Which points regarding discharge summaries must the nurse remember? Select all that apply.

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?

Which actions by the nurse breach patient confidentiality? Select all that apply.

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

Which statements by the new graduate nurse indicate a need for further instruction about documentation? Select all that apply.

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?

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

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?