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.

Answer and Explanation

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

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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.

A. To discuss possible solutions to certain client problems. B. To evaluate the effectiveness of the care given. C. To gather information for the plan of care. D. To provide continuity of care.

Correct Answer is D

Explanation

To provide continuity of care.

A care plan conference is a meeting between the nursing home staff, the resident, and the resident’s family to set measurable, specific goals for the resident to meet during their stay, decide what needs to be done to meet those goals, and decide who in the nursing home is responsible for performing each job necessary to help the resident.The main purpose of this meeting is to provide continuity of care, which means ensuring that the resident receives consistent and coordinated care across different settings and providers.

Choice A is wrong becauseto discuss possible solutions to certain client problemsis not the main purpose of a care plan conference, although it may be one of the topics discussed.

A care plan conference is not meant to address only specific problems, but rather the overall plan of care for the resident.

Choice B is wrong becauseto evaluate the effectiveness of the care givenis not the main purpose of a care plan conference, although it may be one of the outcomes of the meeting.

A care plan conference is not meant to assess only the performance of the staff, but rather the progress of the resident.

Choice C is wrong becauseto gather information for the plan of careis not the main purpose of a care plan conference, although it may be one of the steps involved.

A care plan conference is not meant to collect only information, but rather to use it to develop and update the plan of care.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following abbreviations should the nurse use? (Select all that apply.).

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is participating in a care plan conference for a client who has multiple chronic conditions and complex care needs. What is the main purpose of this meeting?

Correct Answer is D

Explanation

Which of these statements about documentation are true? (Select all that apply.).

A nurse is preparing to document the admission nursing assessment for a client who has pneumonia. Which of the following information should the nurse include in this documentation?

A nurse is documenting an incident report for a medication error that occurred on her unit. Which of the following actions should the nurse take? (Select all that apply.).

A nurse is documenting a client’s admission assessment using a flow sheet. Which of the following information should be included in a flow sheet? (Select all that apply.).

A nurse is using an electronic health record (EHR) system to document care for a client who has pneumonia. Which of the following is an advantage of using an EHR system?

A nurse is giving a change of shift report to the nurse on the next shift. Which of the following statements by the nurse is appropriate for handoff communication?

A nurse is preparing to report a change in a client’s condition to another health care provider. What should the nurse include in the report?

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.).