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.

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Correct Answer is C

Explanation

Assess the client’s understanding and readiness for discharge.

This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.

The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.

Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.

The nurse should not threaten or coerce the client to stay in the hospital against his will.

Choice B is wrong because it is not the priority at this time.

The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.

Choice D is wrong because it is not the first action that the nurse should take.

The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.

A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels.It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.

Some of the benefits of cardiac catheterization are:.

• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.

• It can help determine the best treatment plan for the client based on his or her specific condition and needs.

• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.

• It can reduce the need for more invasive surgery or repeated hospitalizations.

A. Use standardized terminology and abbreviations. B. Enter data as soon as possible after providing care. C. Share login information with other authorized users. D. Review and verify data before saving or submitting. E. Correct errors by drawing a single line through them.

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

Explanation

Choice A is correct because using standardized terminology and abbreviations can improve the clarity, accuracy, and consistency of the documentation in an EHR system.

• Choice B is correct because entering data as soon as possible after providing care can ensure the timeliness, completeness, and validity of the information in an EHR system.

• Choice C is wrong because sharing login information with other authorized users can compromise the security, privacy, and integrity of the EHR system.HIPAA guidelines require that each user has a unique identifier and password to access the EHR system.

• Choice D is correct because reviewing and verifying data before saving or submitting can prevent errors, omissions, and discrepancies in the EHR system.

• Choice E is wrong because correcting errors by drawing a single line through them is a method used for paper records, not electronic records.Electronic records should have a mechanism to track changes and corrections without altering the original data.

:HIPAA Guidelines for Electronic Medical Records:Electronic Health Records - Health IT Playbook.

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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

Correct Answer is C

Explanation

A nurse is using an electronic health record (EHR) system to document the care provided to a client who has pneumonia. The nurse should follow which of the following guidelines when using an EHR system ? (Select all that apply.).

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

Explanation

A nurse is using CBE documentation for a client who has diabetes mellitus. The nurse administers insulin to the client and documents this on a:.

A nurse is teaching a newly hired nurse about the legal aspects of documentation. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg. The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

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 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 using a computerized documentation system in a health care facility. Which of the following actions should the nurse take to ensure confidentiality and security? (Select all that apply.).

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.).

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 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.).