Question 1

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

Accepted Answer

A)   "Occurrence reports track problems and identify areas for quality improvement."
B)   "Occurrence reports are required by the Food and Drug Administration (FD
A)   to report drug errors."
C)   "The Joint Commission requires occurrence reports for all client falls."
D)   "Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence." A

Question 2

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

Accepted Answer

A)   Focuses on a complete list of client problems
B)   Assesses the client in a comprehensive manner
C)   Documents the planning portion of the client's care
D)   Establishes an ongoing plan of care for the client D

Question 3

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

Accepted Answer

A)   "I have had EHR instruction and understand the basics of the system. If I need assistance, I will ask for it."
B)   "The EHR integrates the patient's health information documented by the entire healthcare team into one electronic system."
C)   "The EHR can track problems and errors, which can direct quality improvement efforts in a given institution."
D)   "I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution." D

Question 4

The electronic health record (EHR)is used to document client care management.Which statement(s)below is/are applicable to EHR? Select all that apply.

Accepted Answer

A)   Increases the potential for breaches in confidentiality
B)   Decreases the time spent to complete documentation
C)   Minimizes medical errors through use of alert systems
D)   Communicates the client's plan of care to the healthcare team

Question 5

A client is admitted to the birthing unit to rule out preterm labor.The nurse charts only abnormal findings.This type of charting is a form of:

Accepted Answer

A)   Narrative charting
B)   Charting by inclusion
C)   Charting by exception
D)   Source oriented charting

Question 6

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

A)   09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN
B)   09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN
C)   09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain V.O.: Dr. D. Kelly/Kay Andrews, RN
D)   09/02/16 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

Question 7

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

A)   Repeat the order to the prescriber even if she believes she understood the order correctly.
B)   Immediately notify the pharmacy of the order and verify it with a pharmacist.
C)   Ask the unit secretary to listen to the prescriber on the phone to verify the order.
D)   Transcribe the order on notepaper and verify the dosage in a drug handbook.

Question 8

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

Accepted Answer

A)   Narrative charting tracks the client's changing health status as it occurs.
B)   Free form documentation is inconsistent among healthcare providers.
C)   Less charting time by healthcare provider is needed for narrative charting.
D)   Less interdisciplinary discussion occurs with the narrative style of charting.

Question 9

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?

Accepted Answer

A)   Ensures that the nurse is able to finish the shift as quickly as possible
B)   Provides a guide for the nurse's report to the oncoming nurse
C)   Requires the nurses to engage in walking rounds for the report
D)   Provides a detailed cultural report for Latino patients

Question 10

A resident in a long-term care facility is unable to provide self-care owing to dementia and is receiving Medicare funds.How often must the nurse document this resident's care?

Accepted Answer

A)   Every 2 weeks
B)   Every shift
C)   Every week
D)   Every 3 months

Question 11

A client is admitted to a long-term care facility.The nurse knows that federal law requires the use of:

Accepted Answer

A)   The Minimum Data Set (MDS)  for assessment
B)   Situation-Background-Assessment-Recommendation (SBAR)  for reporting
C)   Health Care Financing Administration guidelines prior to surgery
D)   The Joint Commission guidelines for discharge planning

Question 12

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

Accepted Answer

A)   Teaching performed
B)   Any change in client status
C)   Treatments administered
D)   Hygiene measures performed

Question 13

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

Accepted Answer

A)   Study the discharge plan.
B)   Check the graphic data for vital signs.
C)   Examine the history and physical examination.
D)   Look for an advance directive.

Question 14

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 that the nurse is following the surgeon's order? The nurse:

Accepted Answer

A)   Performs oral care
B)   Assists the patient out of bed
C)   Assists the patient with bathing
D)   Changes the patient's operative dressings

Question 15

Knowing that discharge summary information is integral to the client's ongoing care,which of the point(s)regarding discharge summaries must the nurse be aware? Select all that apply.

Accepted Answer

A)   The discharge summary is important because many clients require follow-up care.
B)   A complete discharge summary is a guide for healthcare professionals in the community.
C)   The nurse can give a verbal transfer report, which is the same as a discharge summary.
D)   The discharge summary is the final note in the client's health record
E)   A complete discharge summary must be handwritten using the narrative note format.

Question 16

The nurse is administering the 0900 dose of heparin 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.The nurse observes petechiae on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding.The correct nursing actions at this time are below.Select all that apply.

Accepted Answer

A)   Notify the prescriber before giving the medication.
B)   Give subcutaneous heparin as ordered.
C)   Hold the medication dose at this time.
D)   Chart the reason the medication was not given.
E)   Assess for other significant signs and symptoms.F)  Record abnormal findings in the patient's health record.

Question 17

Which statement(s)by the student nurse indicates an understanding of the nursing Kardex? Select all that apply.

Accepted Answer

A)   "It pulls data from multiple areas of the patient's chart."
B)   "It is usually kept at the patient's bedside."
C)   "It is used to document patient response to interventions."
D)   "It summarizes the plan of care and guides nursing care."

Question 18

A student nurse makes the following comments to her 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

A)   Narrative
B)   Focus
C)   Source oriented
D)   Problem oriented

Question 19

Which instruction by a registered nurse should the student nurse clarify with her clinical instructor? "When taking off the provider's orders,you should:

Accepted Answer

A)   Write drug names in full-rather than using abbreviations"
B)   Use apothecary units-instead of metric units"
C)   Write 'at' or 'each'-rather than use the '@'symbol"
D)   Write 'mL' or 'milliliters'-in place of the 'cc' abbreviation"

Question 20

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

Accepted Answer

A)   Patient is uncooperative and refuses the prescribed dose of digoxin.
B)   Patient refuses the 0900 dose of digoxin.
C)   Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin.
D)   0900 dose of digoxin not given.

Exam 18: Documenting Reporting

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

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

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

The electronic health record (EHR) is used to document client care management.Which statement(s) below is/are applicable to EHR? Select all that apply.