Chapter 25: Documentation Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. The nurse is preparing the information that will be provided to the staff on the next shift. Which of the following should the nurse include in the intershift report to nursing colleagues?

a.

Audit of client care procedures

b.

The clients diagnosis-related group

c.

All routine care procedures required by the client

d.

Instructions given to the client in a teaching plan

ANS: d

d. A change-of-shift report should include instructions given in a teaching plan and the clients response. This should not include detailed content unless staff members ask for clarification.

a. The nurse should relay to staff significant changes in the way therapies are given, but should not describe basic steps of a procedure.

b. The clients diagnosis-related group is not essential background information to be shared in report.

c. The nurse should not review all routine care procedures or tasks.

REF: Text Reference: p. 496

2. The client climbed over the side rails and fell to the floor. An incident report is to be completed. The correct reporting of an incident involves which of the following?

a.

The nurse witnessing the event completes the report.

b.

Details of the incident are subjectively described.

c.

An explanation of the possible cause for the incident is entered.

d.

A notation is included in the medical record that an incident report was prepared

ANS: a

a. The nurse who witnessed the incident is the one who completes the report.

b. Details of the incident should be objectively described.

c. An explanation of the possible cause is not included. The sequence of events is described objectively.

d. A notation that an incident report was written is not included in the medical record.

REF: Text Reference: p. 497

3. Guidelines should be followed when documenting client care. The nurse recognizes that the following is the most appropriate notation:

a.

1230 Clients vital signs taken

b.

0700 Client drank adequate amount of fluids

c.

0900 Meperidine (Demerol) given for lower abdominal pain

d.

0830 Increased intravenous (IV) fluid rate to 100 ml per hour according to protocol

ANS: d

d. Information within a recorded entry must be complete, containing appropriate and essential information. This notation provides the time and action taken by the nurse, including the reason for doing so.

a. This entry does not indicate what the vital signs were.

b. This entry does not provide a specific amount the client drank. Stating adequate is subjective, not objective.

c. This notation does not have the client describe his or her pain or rate it according to a pain scale for comparison later. It also does not indicate whether the clients pain was in the lower left or lower right quadrant, or both.

REF: Text Reference: p. 482

4. The nurse makes a late entry in a clients record. Which of the following is the best example of how to document this type of situation?

a.

8:30 AM Client received aspirin and oxycodone (Percodan; 1 tablet) PO an hour before going to radiology

b.

12:15 PM I gave the client morphine 10 mg IM at 11:10 AM, but did not document it then

c.

2:45 PM Acetylsalicylic acid (ASA) gr X given for temperature of 38.1 C

d.

8:30 PM Abdominal dressing change at 7:30 PM. No s/s of infection, and wound edges approximating well

ANS: c

c. This is the best example of a late entry. The time is indicated along with the action and an objective observation

a. This notation is not complete. It does not indicate why the aspirin and oxycodone (Percodan) was given (i.e., what was the clients level of pain?) Were was the pain located?

b. The nurse does not need to document about herself, only about the client. In this option, the nurse does not indicate why the morphine was given (clients level of pain? Location of pain?).

d. This entry is not complete. It does not state the size of the wound, type of dressing used, or the clients tolerance of the procedure.

REF: Text Reference: p. 482

5. Client is wheezing and experiencing some dyspnea on exertion. This is an example of:

a.

The S in SOAP documentation

b.

FOCUS documentation

c.

The P of PIE

d.

The R in DAR documentation

ANS: c

c. This datum is an example of the P of PIE because it describes the problem.

a. The S in SOAP documentation represents subjective data (verbalizations of the client).

b. FOCUS charting does not concentrate on only problems. It is structured according to a clients concerns.

d. The R in DAR documentation is the response of the client. This situation describes the clients problem, not the clients response.

REF: Text Reference: p. 484

6. Recording a nurses description of the teaching provided to the client on performance of self-medication administration is found in a(n):

a.

Kardex

b.

Incident report

c.

Nursing history form

d.

Discharge summary form

ANS: d

d. A nurses description of the teaching provided to the client on performance of self-administration of medication is recorded in the discharge summary form.

a. A Kardex is a written form that contains basic client information. A Kardex contains an activity and treatment section and a nursing care plan section that organizes information for quick reference as nurses give change-of-shift report. It does not include a description of teaching that was provided to the client.

b. An incident report concerns any event that is not consistent with the routine operation of a health care unit or routine care of a client (e.g., a client falls).

c. A nursing history form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems. It provides baseline data about the client.

REF: Text Reference: p. 492

7. The nurse is documenting on the clients record and notes that she has made an error. The action that the nurse should take is to:

a.

Draw a straight line through the error and initial it.

b.

Erase the error and write over the material in the same spot.

c.

Use a dark color marker to cover the error and continue immediately after that point.

d.

Footnote the error at the bottom of the page.

ANS: a

a. If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly.

b. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible. Entries should be made only in ink so it cannot be erased.

c. This is not correct. It may appear as if the nurse was attempting to hide something or deface the record.

d. Footnotes are not used in nursing documentation.

REF: Text Reference: p. 480

8. The charge nurse is evaluating the documentation of the new staff nurse. On review of the charting, the charge nurse notes that appropriate documentation is evident when the new staff nurse:

a.

Uses a pencil to make the entries

b.

Uses correction fluid to correct written errors

c.

Identifies an error made by the attending physician

d.

Dates and signs all of the entries made in the record

ANS: d

d. Each entry should begin with the time and end with the signature and title of the person recording the entry.

a. All entries should be recorded legibly and in black ink because pencil can be erased.

b. The nurse should never erase entries or use correction fluid and never use a pencil. The use of correction fluid could make the charting become illegible, and it may appear as if the nurse were attempting to hide something or to deface the record.

c. If the physician made an error, the nurse should not document it in the clients chart. It should be documented in an incident report.

REF: Text Reference: p. 480

9. It is late at night on the medical unit in the hospital and the physician calls to leave orders for one of his clients. The licensed practical nurse (LPN) answers the phone and appropriately responds:

a.

Let me get the registered nurse on the phone.

b.

I am unable to take the order at this time. Please call in the morning.

c.

Please repeat the order for me so I can make sure it is written correctly.

d.

Let me have your phone number, and I will have the supervisor call you back.

ANS: a

a. A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse.

b. This is not an appropriate response and not in the clients best interest.

c. It is best to repeat any prescribed orders back to the physician, who can then verify whether it is correct or clarify the order.

d. This is not the appropriate response. A registered nurse must take the verbal order, but it does not have to be the nursing supervisor.

REF: Text Reference: p. 497

10. A slight hematoma developed on the clients left forearm. The nurse labels the problem as an infiltrated intravenous (IV) line. The nurse elevates the forearm. The client states, My arm feels better. What is documented as the R in FOCUS charting?

a.

My arm feels better

b.

Slight hematoma on left forearm

c.

Infiltrated IV line

d.

Elevation of left forearm

ANS: a

a. The R in FOCUS charting is the clients response. In this case, the nurse would document, My arm feels better.

b. Slight hematoma on left forearm is the D, referring to data in FOCUS charting.

c. Infiltrated IV line would be documented as D, referring to data in FOCUS charting.

d. Elevation of left forearm is the A in FOCUS charting. It describes the action or nursing intervention.

REF: Text Reference: p. 484

11. Which of the following is evaluated as a legally appropriate notation?

a.

Dr. Green made an error in the amount of medication to administer.

b.

Verbalized sharp, stabbing pain along the left side of chest.

c.

Nurse Williams spoke with the client about the surgery.

d.

Client upset about the physical therapy.

ANS: b

b. Entries should be concise, factual, and accurate. This is an example of an objective description of a clients behavior.

a. The nurse should not document physician-made error. Instead, the nurse could chart, Dr. Green was called to clarify order for medication administration.

c. The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry.

d. Only objective descriptions of the clients behavior should be recorded. For example: Client states, I dont want physical therapy! I want to go home!

REF: Text Reference: p. 480, Text Reference: p. 481

12. To avoid legal risks and possible lack of confidentiality associated with computerized documentation, many programs currently have:

a.

All nursing staff use the same access code.

b.

Only centralized medical records use the client data.

c.

Thumbprint identification restrictions.

d.

Periodic changes in staff passwords.

ANS: d

d. A good system of computerized documentation requires periodic changes in personal passwords to prevent unauthorized persons from tampering with records.

a. All nurses do not use the same access code. Each nurse should have his or her own password.

b. This is not a true statement. Authorized health care providers from any department can access and use the data.

c. Many programs do not have thumbprint identification restrictions.

REF: Text Reference: p. 495

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