Review Documenting Nursing Activities (Record System Used in an Agency)

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Documenting Nursing Activities (Record System Used in an Agency)

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Total Questions : 27

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Question 1:

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. The client’s vital signs, oxygen saturation, and respiratory status. B. The client’s medical history, allergies, and current medications. C. The client’s nursing diagnosis, goals, and expected outcomes. D. The client’s family contacts, insurance information, and advance directives.

Answer and Explanation

Choice A:

This is because the admission nursing assessment is a comprehensive evaluation of the client’s physical, mental, emotional, and social status, as well as their current health problems and needs.

The admission assessment provides baseline data for comparison and planning of care.The client’s vital signs, oxygen saturation, and respiratory status are essential components of the admission assessment for a client who has pneumonia, as they reflect the severity of the infection and the risk of complications.

Choice B:

The client’s medical history, allergies, and current medications are part of the health history interview, which is a component of the admission assessment but not the entire documentation.

Choice C:

The client’s nursing diagnosis, goals, and expected outcomes are part of the planning and implementation phases of the nursing process, which come after the assessment phase.

Choice D:

The client’s family contacts, insurance information, and advance directives are part of the administrative data collection, which is not directly related to the client’s health status or nursing care.

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Question 2:

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. Kardexes. B. Flow sheets. C. Progress notes. D. Nursing discharge summaries. E. Care plan conferences.

Answer and Explanation

Choice A:

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 B:

Choice C:

Progress notes are not concise, but rather narrative descriptions of the client’s condition, interventions and outcomes.

Choice D:

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:

Care plan conferences are not records, but meetings where health professionals discuss the client’s needs, goals and progress.

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Question 3:

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. “The client in room 12 is very demanding and complains a lot.”. B. “The client in room 14 has a wound dressing that needs to be changed at 10 a.m.”. C. “The client in room 16 is allergic to penicillin and sulfa drugs.”. D. “The client in room 18 is a 65-year-old male who had a myocardial infarction yesterday.”.

Answer and Explanation

Choice A:

it is subjective and disrespectful to the patient.

It does not convey any useful information about the patient’s condition, needs, or preferences.

It may also create a negative bias or impression on the next nurse, which could affect the quality of care.

Choice B:

This statement is appropriate for handoff communication because it provides relevant and specific information about the patient’s care plan and any pending tasks that need to be completed by the next nurse.

It also allows for the opportunity for discussion and clarification between the nurses.

Choice C:

it is not timely or relevant for handoff communication.

The patient’s allergies should be documented in the electronic health record (EHR) and verified with the patient before administering any medications.

It is not necessary to repeat this information during every handoff, unless there is a change or concern.

Choice D:

it is too vague and incomplete for handoff communication.

It does not provide any details about the patient’s current status, vital signs, medications, interventions, or goals.

It also does not indicate any anticipated changes or potential complications that the next nurse should be aware of.

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Question 4:

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. “I have an order for a chest x-ray for Mr. Jones in room 20.”. B. “Please repeat the order for a chest x-ray for Mr. Jones in room 20.”. C. “You want me to get a chest x-ray for Mr. Jones in room 20, right?.”. D. “I read back the order for a chest x-ray for Mr. Jones in room 20.”.

Answer and Explanation

Choice A:

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:

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:

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.

Choice D:

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.

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Question 5:

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?

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.

Answer and Explanation

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Question 6:

A client who has been hospitalized for two weeks tells the nurse that he wants to go home today because he feels fine now and does not need any more treatment or tests done on him at this time.

The nurse knows that this client is scheduled for a cardiac catheterization tomorrow morning and that his discharge date is not yet determined by his physician.

Which of the following actions should the nurse take first?

A. Inform the client that he cannot leave without a physician’s order. B. Explain the purpose and benefits of the cardiac catheterization to the client. C. Assess the client’s understanding and readiness for discharge. D. Notify the physician and the charge nurse about the client’s request.

Answer and Explanation

Choice A:

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:

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 C:

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 D:

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.

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Question 7:

A nurse is caring for a client who has just undergone surgery for appendicitis.

The nurse documents in the client’s chart : “Client resting comfortably in bed with IV fluids infusing at 125 mL/hr.

Dressing clean , dry , and intact.

No complaints of pain or nausea.

Denies any problems or concerns.” This type of documentation is an example of :.

A. SOAP charting. B. PIE charting. C. Focus charting. D. Narrative charting.

Answer and Explanation

Choice A:

SOAP charting is a type of documentation that is organized by four categories: Subjective, Objective, Assessment, and Plan.

It is commonly used in problem-oriented medical records.

Choice B:

PIE charting is a type of documentation that uses three categories: Problem, Intervention, and Evaluation.

It is based on the nursing process and eliminates the need for a separate care plan.

Choice C:

Focus charting is a type of documentation that uses three categories: Data, Action, and Response.

It emphasizes the patient’s concerns, problems, or strengths rather than medical diagnoses.

Choice D:

Narrative charting.This type of documentation is an example of narrative charting because it chronicles all of the patient’s assessment findings and nursing activities that occurred throughout the shift in a descriptive format.

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Question 8:

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. 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.

Answer and Explanation

Choice A:

Using standardized terminology and abbreviations can improve the clarity, accuracy, and consistency of the documentation in an EHR system.

Choice B:

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:

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:

Reviewing and verifying data before saving or submitting can prevent errors, omissions, and discrepancies in the EHR system.

Choice E:

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.

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Question 9:

Which of these statements about documentation are true?

(Select all that apply.).

A. Documentation should be done as soon as possible after an event has occurred. B. Documentation should include objective data, subjective data, and nursing interventions. C. Documentation should use abbreviations, symbols, and acronyms that are approved by the facility. D. Documentation should include opinions, judgments, and assumptions about the client’s condition. E. Documentation should reflect the nursing process and the standards of care.

Answer and Explanation

Choice A:

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 B:

Choice C:

Choice D:

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:

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.

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Question 10:

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

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.

Answer and Explanation

Choice A:

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 B:

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 C:

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:

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

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Question 11:

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. A summary of all the interventions performed since admission. B. A description of how the nurse feels about the client’s situation. C. A comparison of the client’s condition with other similar cases. D. A statement of facts, changes, trends, and responses to treatment.

Answer and Explanation

Choice A:

A summary of all the interventions performed since admission is too broad and may not reflect the current situation of the client.

Choice B:

A description of how the nurse feels about the client’s situation is subjective and may not be helpful for the other health care provider.

Choice C:

A comparison of the client’s condition with other similar cases is not specific to the individual client and may not account for differences in factors such as age, comorbidities, or preferences.

Choice D:

A statement of facts, changes, trends, and responses to treatment.This is the best way to report a change in a client’s condition to another health care provider because it provides clear, concise, and relevant information that can help with decision making and continuity of care.

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Question 12:

A nurse is using SOAP format to document a client’s progress note.

What does SOAP stand for?

A. Subjective, Objective, Assessment, Plan. B. Situation, Observation, Action, Problem. C. Summary, Outcome, Analysis, Process. D. Source, Opinion, Accuracy, Purpose.

Answer and Explanation

Choice A:

Subjective, Objective, Assessment, Plan.This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.

Choice B:

Situation, Observation, Action, Problemis not a documentation method, but a communication tool used in handovers and briefings.

Choice C:

Summary, Outcome, Analysis, Processis not a documentation method, but a framework for writing reflective essays.

Choice D:

Source, Opinion, Accuracy, Purposeis not a documentation method, but a criteria for evaluating information sources.

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Question 13:

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. “I should document only normal findings to avoid alarming the client.”. B. “I should document any incident that occurs during my shift and notify the provider.”. C. “I should document in advance to save time and ensure accuracy.”. D. “I should document my personal opinions about the client’s condition and care.”.

Answer and Explanation

Choice A:

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 B:

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.

Choice C:

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:

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.

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Question 14:

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?

Answer and Explanation

Choice A:

Choice B:

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.

Choice C:

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:

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Question 15:

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. Log off the system when leaving the workstation. B. Shred any printouts before discarding them. C. Use a personal digital assistant (PDA) to access client information. D. Change the password at regular intervals. E. Report any breaches or attempted breaches to the appropriate authority.

Answer and Explanation

Choice A:

This is a correct action to ensure confidentiality and security of electronic health records (EHRs).

Logging off prevents unauthorized access to client information by other users who may use the same workstation.It also protects the system from malware or cyberattacks that may compromise the data integrity or availability.

Choice B:

This is also a correct action to ensure confidentiality and security of EHRs.

Shredding any printouts that contain client information prevents them from being accessed by unauthorized persons who may find them in the trash or recycling bins.It also complies with the legal and ethical obligations to protect the privacy of clients.

Choice C:

This is an incorrect action to ensure confidentiality and security of EHRs.

Using a PDA to access client information may expose the data to unauthorized access, loss, theft, or damage.

PDAs are typically not encrypted or password-protected, and may not have adequate security features or software updates to prevent cyberattacks or malware infections.PDAs may also not be compatible with the EHR system or follow the data standards and interoperability requirements.

Choice D:

This is another correct action to ensure confidentiality and security of EHRs.

Changing the password at regular intervals reduces the risk of password cracking, guessing, or phishing by unauthorized users or hackers.It also helps to maintain the accountability and authentication of authorized users who access the EHR system.

Choice E:

This is also a correct action to ensure confidentiality and security of EHRs.

Reporting any breaches or attempted breaches to the appropriate authority helps to identify and mitigate the impact of any data loss, corruption, or disclosure.It also helps to comply with the legal and regulatory obligations to notify the affected clients and stakeholders, and to prevent further breaches or incidents.

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Question 16:

A nurse is using the focus charting method to document care for a client who has diabetes mellitus.

Which of the following terms should the nurse use to begin each entry?

A. Data. B. Problem. C. Focus. D. Assessment.

Answer and Explanation

Choice A:

Data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus.

Choice B:

Problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care.

Choice C:

Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions.The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.

The focus charting method uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response, referred to as DAR.

Choice D:

Assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.

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Question 17:

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. It eliminates errors due to illegible handwriting. B. It allows access to multiple clients’ records at once. C. It reduces duplication of documentation among caregivers. D. It provides built-in safeguards to protect confidentiality.

Answer and Explanation

Choice A:

it is not the only advantage of using an EHR system.While it is true that an EHR system eliminates errors due to illegible handwriting, it may also introduce new types of errors such as data entry mistakes, system failures, or unauthorized access.

Choice B:

it is not an advantage of using an EHR system.

In fact, it may be a disadvantage because it poses a risk to the confidentiality and security of the clients’ records.An EHR system should have built-in safeguards to protect the privacy and integrity of the data, such as encryption, passwords, and audit trails.

Choice C:

This is an advantage of using an EHR system because it allows different healthcare providers to access and update the same record, avoiding unnecessary repetition and inconsistency.An EHR system also improves the quality and safety of care by providing clinical decision support, reducing medication errors, and facilitating communication among caregivers.

Choice D:

it is not an advantage of using an EHR system.It is a requirement of any health record system, whether electronic or paper-based, to comply with the ethical and legal standards of confidentiality.

An EHR system does not provide any additional safeguards that are not already present in a paper-based system.

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Question 18:

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. Include factual information about what happened. B. State opinions about who was responsible for the error. C. File the report in the client’s medical record. D. Notify the risk management department. E. Discuss possible solutions to prevent future errors.

Answer and Explanation

Choice A:

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:

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:

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 D:

Choice E:

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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Question 19:

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. Vital signs. B. Allergies. C. Medication administration. D. Medical history. E. Intake and output.

Answer and Explanation

Choice A:

vital signs are one of the most common and important data that need to be recorded and monitored regularly for any patient.

Choice B:

because allergies are essential information that can affect the patient’s treatment plan and prevent adverse reactions.

Choice C:

medication administration is another crucial data that shows what drugs, doses, routes and times the patient has received or will receive.

Choice D:

medical history is not a routine or frequent data that needs to be recorded in a flow sheet.Medical history is usually documented in a separate form that provides more details and background information about the patient’s past and present health conditions.

Choice E:

intake and output are important data that indicate the patient’s fluid balance and renal function.

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Question 20:

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.).

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.

Answer and Explanation

Choice A:

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 B:

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 C:

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:

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:

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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Question 21:

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. Redness, swelling, and warmth of the affected area. B. Pain level rated as 8/10 on a numerical scale C. C. Wound culture results pending. D. Risk for infection related to impaired skin integrity. E. Applied moist heat compresses to the wound site.

Answer and Explanation

Choice A:

These are the only options that describe thesubjectiveandobjectivedata of the patient, which are part of theSOAPdocumentation method.SOAP stands forSubjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.

Choice B:

Choice C:

Wound culture results are not part of the assessment entry in SOAP documentation.They are part of the investigation results, which are usually documented in the objective section.

Choice D:

Risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment.Nursing diagnoses are usually documented in the plan section of SOAP documentation.

Choice E:

Applied moist heat compresses to the wound site is an intervention, not an assessment.Interventions are also documented in the plan section of SOAP documentation.

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Question 22:

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. Graphic record. B. Daily care record. C. Medication administration record. D. Client teaching record.

Answer and Explanation

Choice A:

a graphic record is a document that shows the trends of vital signs, intake and output, weight, and other measurements over time.

A graphic record does not include information about medications.

Choice B:

A daily care record is a document that records the routine care activities that have been performed for a patient, such as hygiene, nutrition, elimination, mobility, and comfort measures.

A daily care record does not include information about medications.

Choice C:

A medication administration record (MAR) is a document that records the medications that have been given to a patient, including the dose, route, time, and nurse’s initials.

A MAR is an essential part of nursing documentation and ensures safe and accurate medication administration.

Choice A is wrong because a graphic record is a document that shows the trends of vital signs, intake and output, weight, and other measurements over time.

A graphic record does not include information about medications.

Choice D:

A client teaching record is a document that records the education that has been provided to a patient or family, such as disease process, medications, diet, exercise, self-care, and discharge planning.

A client teaching record does not include information about medication administration.

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Question 23:

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. Specifies the plan of care for clients with different diagnoses. B. Provides guidelines for managing clients with similar health problems. C. Describes the roles and responsibilities of each member of the health care team. D. Evaluates the quality and cost-effectiveness of care delivered to clients.

Answer and Explanation

Choice A:

a critical pathway does not specify the plan of care for clients with different diagnoses, but rather for a specific group of patients with a predictable clinical course.

Choice B:

A critical pathway provides guidelines for managing clients with similar health problems.According to the definition from Wikipedia, a critical pathway is one of the main tools used to manage the quality in healthcare concerning the standardisation of care processes.It has been shown that their implementation reduces the variability in clinical practice and improves outcomes.

Choice C:

a critical pathway does not describe the roles and responsibilities of each member of the health care team, but rather defines, optimizes and sequences the different tasks (interventions) by the professionals involved in the patient care.

Choice D:

a critical pathway does not evaluate the quality and cost-effectiveness of care delivered to clients, but rather aims to promote organised and efficient patient care based on evidence-based medicine.

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Question 24:

A nurse is working in an agency that uses EHR for documentation.

Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information?

(Select all that apply.).

A. Use a personal password to access the system and log off when finished. B. Share the password with other nurses who need to access the system. C. Print out a copy of the client’s record and store it in a locked cabinet. D. Report any breaches or attempted breaches of security to the appropriate personnel. E. Delete any information that is incorrect or outdated from the system.

Answer and Explanation

Choice A:

The nurse should use a personal password to access the system and log off when finished, and report any breaches or attempted breaches of security to the appropriate personnel.

These actions ensure confidentiality and security of the client’s information by preventing unauthorized access and disclosing any violations.

Choice B:

sharing the password with other nurses who need to access the system violates the principle ofminimum necessary access, which means that only those who need the information for a specific purpose should have access to it.

Choice C:

printing out a copy of the client’s record and storing it in a locked cabinet creates a risk ofloss, theft, or unauthorized disclosureof the paper record.The nurse should avoid printing out electronic health records unless absolutely necessary, and should follow the proper disposal procedures if they do.

Choice D:

The nurse should use a personal password to access the system and log off when finished, and report any breaches or attempted breaches of security to the appropriate personnel.

These actions ensure confidentiality and security of the client’s information by preventing unauthorized access and disclosing any violations.

Choice E:

deleting any information that is incorrect or outdated from the system may compromise theintegrity and availabilityof the client’s information.The nurse should follow the established policies and procedures for correcting or updating electronic health records, which may include adding an addendum or annotation to the original entry, but not deleting it.

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Question 25:

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?

A. Home health certification and plan of treatment. B. Outcome and assessment information set. C. Home care flow sheet. D. Home care progress note.

Answer and Explanation

Choice A:

Home health certification and plan of treatment.This is the record that the nurse uses to certify that the client meets Medicare eligibility criteria and to outline the services to be provided.A home health certification and plan of treatment is a document that contains the physician’s or allowed practitioner’s orders for home health services, the patient’s diagnosis, the patient’s functional limitations, the type and amount of services needed, and the expected duration of care.

Choice B:

Outcome and Assessment Information Set (OASIS)is a standardized assessment tool that HHAs use to collect data on adult patients receiving skilled services.

OASIS is not used to certify eligibility or plan treatment.

Choice C:

Home care flow sheetis a form that HHAs use to document the daily care provided by nurses and home health aides.

A home care flow sheet does not certify eligibility or plan treatment.

Choice D:

Home care progress noteis a form that HHAs use to document the patient’s progress toward the goals of care, any changes in the plan of care, and any communication with other health care providers.

A home care progress note does not certify eligibility or plan treatment.

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Question 26:

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. Daily weight, blood pressure, and pulse B. Medication administration record. C. Nursing diagnosis and care plan. D. Discharge planning and referral summary.

Answer and Explanation

Choice A:

A flow sheet is a type of document that records specific information in a structured and concise way, such as vital signs, fluid intake and output, pain level, etc.A flow sheet is useful for clinical communication and tracking the patient’s condition over time.A medication administration record (MAR) is a separate document that records the medications given to the patient, the dosage, the route, and the time.A nursing diagnosis and care plan is a document that identifies the patient’s problems and goals, and the interventions to achieve them.A discharge planning and referral summary is a document that outlines the patient’s needs and resources after leaving the facility, such as follow-up appointments, home care services, etc.

Choice B:

a MAR is not a flow sheet.

Choice C:

a nursing diagnosis and care plan is not a flow sheet.

Choice D:

a discharge planning and referral summary is not a flow sheet.

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Question 27:

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. O2. B. NC. C. LPM. D. SpO2. E. RR.

Answer and Explanation

Choice A:

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 B:

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:

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.

Choice D:

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 E:

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.

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Documenting Nursing Activities (Record System Used in an Agency)

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