A nurse is reviewing the record system used in an agency.
Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals?
(Select all that apply.).
Kardexes.
Flow sheets.
Progress notes.
Nursing discharge summaries.
Care plan conferences.
Correct Answer : A,B
Kardexes and flow sheets are types of records that are used for documenting concise data about a client and making information quickly accessible to all health professionals. Kardexes are a series of cards kept in a portable index file or on computer generated forms that contain a problem list, stated goals and list of nursing approaches to meet the goals. Flow sheets are forms that allow for recording routine aspects of care such as vital signs, intake and output, medications, etc.
Choice C is wrong because progress notes are not concise, but rather narrative descriptions of the client’s condition, interventions and outcomes. Choice D is wrong because nursing discharge summaries are not used for quick access, but rather for providing information about the client’s hospitalization, treatment and follow-up care. Choice E is wrong because care plan conferences are not records, but meetings where health professionals discuss the client’s needs, goals and progress.
Normal ranges for vital signs are as follows:.
• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).
• Pulse: 60 to 100 beats per minute.
• Respiration: 12 to 20 breaths per minute.
• Blood pressure: less than 120/80 mmHg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
The nurse should use the following abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min:.
• O2: This stands for oxygen and indicates the type of gas being delivered to the patient.
• NC: This stands for nasal cannula and indicates the device used to deliver oxygen to the patient.
• SpO2: This stands for peripheral oxygen saturation and indicates the percentage of hemoglobin that is saturated with oxygen in the blood.
It is measured by a pulse oximeter attached to the patient’s finger or earlobe.
• RR: This stands for respiratory rate and indicates the number of breaths per minute that the patient takes.
It is an important vital sign to monitor in patients with respiratory conditions.
Choice C is wrong because LPM is not an accepted abbreviation for oxygen therapy.LPM stands for liters per minute and indicates the flow rate of oxygen being delivered to the patient.However, it should not be abbreviated as LPM, but written out in full or as L/min.This is to avoid confusion with other abbreviations such as lpm (lowercase L) which stands for light per minute, a unit of luminous flux.
Normal ranges for SpO2 and RR vary depending on the age, health status and activity level of the patient, but generally they are:.
• SpO2: 95% to 100% for healthy adults.
Lower values may indicate hypoxemia (low blood oxygen level) or other conditions affecting oxygen delivery or uptake in the body.
• RR: 12 to 20 breaths per minute for healthy adults.
Higher or lower values may indicate respiratory distress, infection, pain, anxiety or other conditions affecting breathing.
Correct Answer is ["A","D"]
Explanation
The nurse should include factual information about what happened and notify the risk management department.These actions are part of the steps of reporting medication errorsand the good practice guide on recording, coding, reporting and assessment of medication errors.
Choice B is wrong because the nurse should not state opinions about who was responsible for the error.
This could be seen as biased, unprofessional or accusatory.
The nurse should focus on the facts and the causes of the error, not on blaming individuals.
Choice C is wrong because the nurse should not file the report in the client’s medical record.
This could violate the client’s privacy and confidentiality.
The report should be filed in a separate system that is accessible only to authorized personnel.
Choice E is wrong because the nurse should not discuss possible solutions to prevent future errors.
This could be premature, unrealistic or inappropriate.
The nurse should leave this task to the investigation team or the risk management department, who will analyse the incident and make recommendations based on evidence and best practice.
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