Review Purposes/Reasons for Client Records

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Purposes/Reasons for Client Records

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Total Questions : 5

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Question 1:

A nurse is reviewing the client records of a health care facility.

Which of the following purposes of client records is the nurse performing?

A. Communication. B. Planning client care C. C. Auditing health agencies. D. Research.

Answer and Explanation

Choice A:

The nurse is performing one of the main purposes of client records, which is to communicate with other health care providers about the client’s condition, needs, and interventions.Communication is essential for ensuring continuity and quality of care, as well as for preventing errors and misunderstandings.

Choice B:

Planning client care is not the purpose of reviewing client records, but rather the purpose of creating and updating them.Planning client care involves setting goals, choosing interventions, and evaluating outcomes based on the information in the client records.

Choice C:

Auditing health agencies is not the purpose of reviewing client records by a nurse, but rather the purpose of examining them by an external or internal agency.Auditing health agencies involves assessing the quality, efficiency, and effectiveness of health care services based on the client records.

Choice D:

Research is not the purpose of reviewing client records by a nurse, but rather the purpose of using them by researchers.Research involves collecting, analyzing, and interpreting data from client records to generate new knowledge, improve practice, or inform policy.

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Question 2:

A nurse is documenting the care provided to a client in the electronic health record (EHR).

Which of the following actions should the nurse take?

(Select all that apply.).

A. Use standardized terminology and abbreviations. B. Include the date and time of each entry. C. Delete any incorrect information with a single line D. D. Sign each entry with the nurse’s name and credentials. E. Share the password with other authorized staff.

Answer and Explanation

Choice A:

Standardized terminology and abbreviations can improve communication, consistency and data collection among health care providers.

Choice B:

The date and time of each entry can provide accurate and timely information about the patient’s condition and care.

Choice C:

Deleting any incorrect information with a single line is not appropriate for electronic health records.Instead, the nurse should use the correction function of the EHR system to make any changes.

Choice D:

Signing each entry with the nurse’s name and credentials can ensure accountability and responsibility for the documentation.

Choice E:

Sharing the password with other authorized staff can facilitate access to the patient’s information when needed.However, the nurse should also protect the password and security of the EHR system by closing it when not in use and not disclosing it to unauthorized persons.

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Question 3:

A nurse is preparing a report for a client who is being transferred to another unit.

Which of the following statements should the nurse include in the report?

A. “The client is alert and oriented to person, place, and time.”. B. “The client has a history of hypertension and diabetes.”. C. “The client’s vital signs are stable and within normal limits.”. D. “The client needs assistance with bathing and dressing.”.

Answer and Explanation

Choice A:

This statement provides the most relevant and current information about the client’s mental status and level of consciousness, which are important for the receiving nurse to know.

Choice B:

It does not specify the current status of the client’s hypertension and diabetes, such as blood pressure, blood glucose, medications, or complications.

This information is more appropriate for a written summary or a discharge report.

Choice C:

It does not provide the actual values of the client’s vital signs, which can vary depending on the client’s condition and baseline.

The receiving nurse should know the exact numbers to monitor for any changes or abnormalities.

Choice D:

It does not indicate the reason why the client needs assistance with bathing and dressing, such as mobility issues, pain, or weakness.

This information is also less urgent than the client’s mental status and vital signs.

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Question 4:

A client asks a nurse why it is necessary to document every aspect of care in the record.

Which of the following responses should the nurse give?

A. “It helps us to communicate with other members of the health care team.”. B. “It helps us to get reimbursed for the services we provide.”. C. “It helps us to protect ourselves from legal liability.”. D. “It helps us to improve the quality of care we deliver.”.

Answer and Explanation

Choice A:

Nursing documentation is essential for clinical communication.Documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver individualised care.

Choice B:

Reimbursement is not the primary purpose of nursing documentation, although it may be a secondary benefit.

Choice C:

Legal liability is not the main reason for documenting care, although it may provide evidence in case of litigation.

Choice D:

Quality improvement is not the direct result of nursing documentation, although it may be facilitated by it.

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Question 5:

A nurse is conducting a research study on the effectiveness of a new wound dressing.

Which of the following sources of data should the nurse use?

A. Client records. B. Client interviews. C. Client surveys. D. Client observations.

Answer and Explanation

Choice A:

This is because client records contain objective and measurable data on the wound healing process, such as size, depth, drainage, infection, and pain.

Client records are also reliable and valid sources of data that can be easily accessed and compared.

Choice B:

Client interviews are subjective and may not reflect the actual effectiveness of the wound dressing.

Client interviews may also be influenced by factors such as mood, recall, and rapport.

Choice C:

Client surveys are also subjective and may not capture the relevant aspects of wound healing.

Client surveys may also have low response rates or biased responses.

Choice D:

Client observations are not enough to evaluate the effectiveness of a wound dressing.

Client observations may be affected by personal preferences, expectations, or beliefs.

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Purposes/Reasons for Client Records

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