Which of these statements about documentation are true?

(Select all that apply.).

Documentation should be done as soon as possible after an event has occurred.

Documentation should include objective data, subjective data, and nursing interventions.

Documentation should use abbreviations, symbols, and acronyms that are approved by the facility.

Documentation should include opinions, judgments, and assumptions about the client’s condition.

Documentation should reflect the nursing process and the standards of care.

Answer and Explanation

Correct Answer : A,B,C

Documentation should be done as soon as possible after an event has occurred, because this ensures accuracy, timeliness, and continuity of care. Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs. Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.

Choice D is wrong because documentation should not include opinions, judgments, or assumptions about the client’s condition, as these are not based on facts or evidence and may be biased or inaccurate. Documentation should be factual, accurate, and objective.

Choice E is wrong because documentation should reflect the nursing process and the standards of care, but this is not a complete statement. Documentation should also reflect the patient’s perspective, preferences, and goals. Documentation should be patient-centered, holistic, and individualized.

Normal ranges for clinical observations vary depending on the patient’s age, health status, and other factors.

However, some general ranges are:.

• Temperature: 36.5°C to 37.5°C.

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: 120/80 mmHg or lower.

• Oxygen saturation: 95% or higher.

Sources:.

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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. It eliminates errors and inaccuracies in documentation. B. It allows access to client information from multiple locations. C. It reduces the need for verbal or written communication among health care providers. D. It protects client information from unauthorized disclosure or alteration.

Correct Answer is B

Explanation

It allows access to client information from multiple locations.

This is an advantage of using a computerized system for documentation and reporting because it enables health care providers to access relevant and updated information about their clients from different locations, such as hospitals, clinics, or home care settings.This can improve the quality and continuity of care, as well as facilitate communication and collaboration among different members of the health care team.

Choice A is wrong because it is not true that a computerized system eliminates errors and inaccuracies in documentation.While a computerized system can reduce some types of errors, such as illegible handwriting or misplaced files, it can also introduce new types of errors, such as data entry mistakes, software glitches, or system failures.

Choice C is wrong because it is not true that a computerized system reduces the need for verbal or written communication among health care providers.On the contrary, a computerized system can enhance communication by allowing health care providers to share information more easily and quickly, but it does not replace the need for verbal or written communication to clarify, confirm, or discuss the information.

Choice D is wrong because it is not true that a computerized system protects client information from unauthorized disclosure or alteration.

While a computerized system can provide some security features, such as passwords, encryption, or audit trails, it can also pose some risks, such as hacking, phishing, or malware attacks.Therefore, health care providers need to follow ethical and legal guidelines to ensure the confidentiality and integrity of client information in a computerized system.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

What is one advantage of using a computerized system for documentation and reporting?

Correct Answer is B

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 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.).

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 a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility. Which of the following data should the nurse record on this type of document?

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 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?

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.).

Which of these statements about documentation are true?

(Select all that apply.).