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?

“I should document only normal findings to avoid alarming the client.”.

“I should document any incident that occurs during my shift and notify the provider.”.

“I should document in advance to save time and ensure accuracy.”.

“I should document my personal opinions about the client’s condition and care.”.

Answer and Explanation

The Correct Answer is B

“I should document any incident that occurs during my shift and notify the provider.” This statement indicates an understanding of the legal aspects of documentation, which include:.

• Documenting accurately, objectively, and completely to provide evidence of care delivery and support the nurse’s moral and legal responsibilities.

• Documenting any change in the patient’s condition, treatments, medications, interventions, client responses, and complaints.

• Documenting any incident that occurs during the shift and notifying the provider to ensure appropriate follow-up and prevent further harm.

• Documenting in a timely manner to minimize errors and omissions.

The other choices are wrong because:.

• Choice A is wrong because documenting only normal findings can mislead the client and other health professionals about the actual status of the client. It can also impede patient care and hinder the nurse’s legal defense in the event of a malpractice lawsuit.

• Choice C is wrong because documenting in advance can compromise the accuracy and integrity of the documentation. It can also lead to legal action if the documented events do not match the actual events.

• Choice D is wrong because documenting personal opinions about the client’s condition and care can be considered unprofessional, biased, and disrespectful. It can also damage the nurse-client relationship and expose the nurse to legal liability.

Normal ranges for documentation depend on the type of information being documented, such as vital signs, laboratory values, assessment findings, etc.

They may vary according to different sources and standards.

Nurses should follow the policies and procedures of their institution and use their clinical judgment when documenting abnormal findings.

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Correct Answer is D

Explanation

“I read back the order for a chest x-ray for Mr. Jones in room 20.”.

This is the best way to verify a telephone order from a radiologist, as it ensures that the nurse has accurately transcribed the order and that the radiologist has confirmed it.

Reading back the order also allows the nurse to clarify any doubts or questions about the order, such as the urgency, the reason, or the patient’s condition.

Choice A is wrong because it does not verify the order, but simply repeats it.

The nurse should not assume that the order is correct without confirmation from the radiologist.

Choice B is wrong because it asks the radiologist to repeat the order, which is inefficient and may cause confusion or errors.

The nurse should repeat the order to the radiologist, not the other way around.

Choice C is wrong because it uses a closed-ended question that can be answered with a yes or no, which may not reflect the radiologist’s true intention or understanding of the order.

The nurse should use an open-ended statement that requires the radiologist to acknowledge or correct the order.

According to federal regulations and accreditation standards, verbal and telephone orders should be authenticated by the prescriber within a specified time frame, usually 24 hours.Some states may have different or more stringent requirements, so nurses should be familiar with their state laws and regulations.Verbal and telephone orders should also be documented and signed by two nurses or one nurse and one enrolled endorsed nurse for verification and administration.

A. It highlights the client’s concerns and strengths. B. It reduces redundancy and duplication of data. C. It facilitates communication among health care team members. D. It incorporates nursing diagnoses and care plans. E. It provides a chronological record of events.

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

Explanation

Focus charting is a method of organizing health information in an individual’s record that centers on the patient’s concerns and strengths.It uses a three-column format to document the data, action and response (DAR) of each focus.

The advantages of using focus charting are:.

• It highlights the client’s concerns and strengths, which makes the care more patient-centered and holistic.

• It reduces redundancy and duplication of data, as it avoids repeating information that is already recorded in other forms or flow sheets.

• It facilitates communication among health care team members, as it promotes interdisciplinary documentation and helps organize the information in a concise and precise way.

Choice D is wrong because focus charting does not incorporate nursing diagnoses and care plans, although it is based on the nursing process.Nursing diagnoses and care plans are documented separately or as part of the action category.

Choice E is wrong because focus charting does not provide a chronological record of events, but rather organizes the data by the focus.A chronological record of events can be found in other forms of documentation, such as narrative or SOAP notes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking a telephone order from a radiologist for a client who needs an urgent chest x-ray. Which of the following statements by the nurse is correct for verifying the order?

Correct Answer is D

Explanation

A nurse is using focus charting to document a client’s progress notes. What are the advantages of using focus charting? (Select all that apply.).

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

Explanation

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 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.).

A nurse is documenting the care provided to a client who receives home health services. Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?

Which of these statements about documentation are true? (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 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 a critical pathway for a client who has chronic obstructive pulmonary disease (COPD). The nurse should understand that a critical pathway:.

A nurse is using SOAP format to document a client’s progress note. What does SOAP stand for?

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?