Chapter 26: Documentation and Informatics Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

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 inter-shift report to nursing colleagues?

1.

Audit of client care procedures

2.

The clients diagnostic-related group

3.

All routine care procedures required by the client

4.

Instructions given to the client in a teaching plan

ANS: 4

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. The nurse should relay to staff significant changes in the way therapies are given, but should not describe basic steps of a procedure. The clients diagnosis-related group is not essential background information to be shared in an inter-shift report. The nurse should not review all routine care procedures or tasks.

DIF: A REF: 399 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

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

1.

The witnessing nurse completes the report.

2.

Details of the incident are subjectively described.

3.

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

4.

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

ANS: 1

The nurse who witnessed the incident is the one who completes the report. Details of the incident should be objectively described. An explanation of the possible cause is not included. The sequence of events is described objectively. A notation is not included in the medical record that an incident report was written.

DIF: A REF: 403 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

3. Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?

1.

1230Clients vital signs taken.

2.

0700Client drank adequate amount of fluids.

3.

0900Demerol given for lower abdominal pain.

4.

0830Increased IV fluid rate to 100 mL/hr according to protocol.

ANS: 4

Information within a recorded entry needs to be complete, containing appropriate and essential information. This notation (0830) provides the time and action taken by the nurse including the reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry (0700) does not provide the specific amount the client drank. Stating adequate is subjective, not objective. This notation (0900) 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.

DIF: A REF: 389 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

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?

1.

2:45 PMASA gr X given for temperature of 38.1 C.

2.

8:30 AMClient received Percodan (1 tablet) PO an hour before going to radiology.

3.

12:15 PMI gave the client morphine 10 mg IM at 11:10 AM but did not document it then.

4.

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

ANS: 1

This is the best example of a late entry. The time (2:45 PM) is indicated along with the action and an objective observation. This notation (8:30 AM) is not complete. It does not indicate why the Percodan was given. What was the clients level of pain? Where was the pain located? The nurse does not need to document about herself; only the client. In this option (12:15 PM), the nurse does not indicate why the morphine was given (clients level of pain? location of pain?). This entry (8:30 PM) is not complete. It does not state the size of the wound, type of dressing used, or the clients tolerance of the procedure.

DIF: A REF: 389 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

5. The following statement: Upon exertion, the client is wheezing and experiencing some dyspnea, is an example of:

1.

The P of PIE

2.

FOCUS documentation

3.

The R in DAR documentation

4.

The S in SOAP documentation

ANS: 1

These data are examples of the P of PIE because they describe the problem. FOCUS charting does not concentrate on only problems. It is structured according to a clients concerns. The R in DAR documentation is the response of the client. This situation describes the clients problem, not the clients response. The S in SOAP documentation represents subjective data (verbalizations of the client).

DIF: A REF: 391 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

6. To locate the recording of a nurses description of the teaching provided to the client on performance of self-medication administration, one would look in a(n):

1.

Kardex

2.

Incident report

3.

Nursing history form

4.

Discharge summary form

ANS: 4

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

DIF: A REF: 397-398 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

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

1.

Draw a straight line through the error and initial it.

2.

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

3.

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

4.

Footnote the error at the bottom of the page.

ANS: 1

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. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible. Also, entries should only be made in ink so they cannot be erased. Using a dark color marker to cover the error is not correct. It may appear as if the nurse was attempting to hide something or deface the record. Footnotes are not used in nursing documentation.

DIF: A REF: 388-389 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

8. The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:

1.

Uses a pencil to make the entries

2.

Uses correction fluid to correct written errors

3.

Identifies an error made by the attending physician

4.

Dates and signs all of the entries made in the record

ANS: 4

Each entry should begin with the time and end with the signature and title of the person recording the entry. All entries should be recorded legibly and in black ink because pencil can be erased. The nurse should never erase entries, never use correction fluid, or 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. If the physician made an error, the nurse should not document it in the clients chart. It should be documented in an incident report.

DIF: A REF: 389 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

9. What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.

1.

Let me get the Registered Nurse on the phone.

2.

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

3.

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

4.

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

ANS: 1

A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. Saying that an order is unable to be taken and to call back in the morning is not an appropriate response and not in the clients best interest. It is best to repeat any prescribed orders back to the physician, who can then verify if it is correct or clarify the order. This is not the appropriate response. A registered nurse needs to take the verbal order, but it does not have to be the nursing supervisor.

DIF: A REF: 402 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

10. The client developed a slight hematoma on his 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?

1.

Infiltrated IV line

2.

My arm feels better

3.

Elevation of left forearm

4.

Slight hematoma on left forearm

ANS: 2

The R in FOCUS charting is the clients response. In this case, the nurse would document, My arm feels better. Infiltrated IV line would be documented as D referring to data in FOCUS charting. Elevation of left forearm is the A in FOCUS charting. It describes the action or nursing intervention. Slight hematoma on left forearm is the D referring to data in FOCUS charting.

DIF: A REF: 391 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

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

1.

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

2.

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

3.

Nurse Williams spoke with the client about the surgery.

4.

Client upset about the physical therapy.

ANS: 2

Entries should be concise, factual, and accurate. Verbalized sharp, stabbing pain along the left side of chest is an example of an objective description of a clients behavior. The nurse should not document physician made error. Instead, the nurse could chart that Dr. Green was called to clarify order for medication administration. The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry. Only objective descriptions of the clients behavior should be recorded. For example: Client states, I dont want physical therapy! I want to go home!

DIF: A REF: 388-389 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

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

1.

Periodic changes in staff passwords

2.

Thumbprint identification restrictions

3.

All nursing staff uses the same access code

4.

Only centralized medical records use the client data

ANS: 1

A good system of computerized documentation requires periodic changes in personal passwords to prevent unauthorized persons form tampering with records. Many programs do not have thumbprint identification restrictions. All nurses do not use the same access code. Each nurse should have his or her own password. Only centralized medical records using the client data is not a true statement. Authorized health care providers from any department can access and use the data.

DIF: A REF: 406 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

13. Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy?

1.

Medicare reviews client charts to determine care given.

2.

Good charting results in good Medicare reimbursement.

3.

Our nursing salaries are paid for by the Medicare reimbursement funds.

4.

The hospital is reimbursed for the nursing care documented in the client chart.

ANS: 4

Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each diagnosis-related group (DRG). Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs.

DIF: C REF: 387 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

14. The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment:

1.

Secured

2.

Accessible

3.

Confidential

4.

Documented

ANS: 3

Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a clients examination, observation, conversation, or treatment with other clients or staff not involved in the clients care. The other options are primarily directed towards written records and are not ethically oriented.

DIF: A REF: 385 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

15. Which of the following nursing statements regarding the release of a clients medical record to another institution requires immediate follow-up by the nurses manager?

1.

Im pretty sure this will require the clients permission.

2.

Are you sure of the exact policy? Do you know what I should do?

3.

The client agreed to the consultation, so Ill have the chart sent over.

4.

I think the client will need to give a verbal consent before it can be sent.

ANS: 3

Each institution has policies to control the manner for sharing records. In most situations, clients are required to give written permission for release of medical information. The other options have the nurse asking for help or expressing doubt about the proper protocol for the release of the records; these would be appropriate statements and the manager should provide the correct information.

DIF: C REF: 385 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

16. Regarding access to client records, the nursing faculty informs the nursing students to be prepared to:

1.

Show the unit staff proper student identification

2.

Sign a confidentiality agreement when on the unit to preplan

3.

Review the medical record only in the presence of unit staff

4.

Obtain permission from the client to access his or her medical record

ANS: 1

When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, they obtain appropriate authorization according to agency policy. Nursing students and faculty may be required to present identification indicating access to the record is authorized. The remaining options are not required if the student is properly identified and shows need to access the material.

DIF: C REF: 385 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

17. Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care?

1.

Notifying the client of the institutions privacy policy

2.

Denying nonessential personal access to the clients medical records

3.

Acquiring the clients verbal consent to share his or her medical record with essential personnel

4.

Requiring that the client sign the Health Insurance Portability and Accountability Act (HIPAA) form

ANS: 1

Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in order to eliminate barriers that could delay access to care, required only that health care providers notify clients of their privacy policy and make a reasonable effort to get written acknowledgment of this notification.

DIF: A REF: 385 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

18. When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider, this is called a:

1.

Referral

2.

Consultation

3.

Transfer report

4.

Multidisciplinary meeting

ANS: 1

Referrals are the request for services by another care provider usually for the purpose of determining appropriate client care. Consultations are a form of discussion whereby one professional caregiver actually gives formal advice about the care of a client to another caregiver. The remaining options are methods of exchanging general information regarding a client.

DIF: A REF: 386 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

19. Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?

1.

Client was angry because breakfast was not to her liking.

2.

Client is depressed; was observed crying while alone in room.

3.

Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists.

4.

Client was verbally abusive to staff when approached concerning clients continued attempts to smoke in the bathroom.

ANS: 3

Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objectively describe the noted client behavior.

DIF: C REF: 388-389 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

20. Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data?

1.

Client was angry because breakfast was not to her liking.

2.

Client is depressed; was observed crying while alone in room.

3.

Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists.

4.

Client was verbally abusive to staff when approached concerning clients continued attempts to smoke in the bathroom.

ANS: 2

Do not write personal opinions. Document observable, measurable client-oriented data only. Recording that the client is depressed based on the observation of tears is not objective and so is not acceptable. While one option does report only observable, measurable behavior, the remaining options, while noting observed client behavior, do fail to objectively describe the noted client behavior.

DIF: C REF: 388-389 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

21. Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation?

1.

The fact that the client refused the prescribed antidepressant medication was noted in his chart.

2.

I provided a detailed description of the dressing change in the clients chart in order to show it was done as prescribed.

3.

The clients wife told me he often develops a rash when he comes into contact with scented soaps, so I noted that in his chart.

4.

I had a long conversation with the client concerning his fears about his upcoming surgery and I mentioned his concerns in my nursing note.

ANS: 2

Common charting mistakes that can result in malpractice include the following: (1) failing to record pertinent health or drug information; (2) failing to record nursing actions; (3) failing to record that medications have been given; (4) failing to record drug reactions or changes in clients condition; (5) writing illegible or incomplete records; and (6) failing to document a discontinued medication. Detailed descriptions of procedures are not included in the nursing notes.

DIF: C REF: 388 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

22. The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a clients medical record is:

1.

James Thicket, NS, WVU

2.

J. Jones, NS, Montclair Shores College

3.

N.H, SN, Bellfield City Community College

4.

Linda Mozden, SN, Fairmont State University

ANS: 4

A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and educational institution, such as David Jones, SN (student nurse), CMTC (Central Maine Technical College).

DIF: A REF: 389 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

23. The nurse realizes that the incorrect spelling of terms in the medical record most importantly:

1.

Shows a lack of competency

2.

Displays little attention to detail

3.

Contributes to serious treatment errors

4.

Negatively affects the accuracy of the documentation

ANS: 3

Spelling errors can result in serious treatment errors; for example, the names of certain medications such as digitoxin and digoxin or morphine and Numorphan are similar. Misspelling such terms can result in medication errors that may cause serious harm to a client. The other options are correct but do not have the seriousness of client care errors.

DIF: C REF: 389 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

24. Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

1.

His surgery corrected the mobility problem, so I drew a line through it and dated it.

2.

The clients problem list has several resolved problems on it; should I take them off?

3.

The client no longer has anxiety issues so I highlighted that problem on his problem list.

4.

He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list.

ANS: 4

New problems are added as they are identified. When a problem has been resolved, record the date and highlight it or draw a line through the problem and its number. Erasure is not an acceptable method of showing that a problem has been resolved.

DIF: A REF: 390-391 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

25. Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

1.

Risk for injury related to falling due to dizziness

2.

Client fell while walking to bathroom unassisted

3.

Client continues to report periods of dizziness upon sitting up

4.

Educated to the purpose of dangling on the bedside before standing

ANS: 1

The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention.

DIF: A REF: 391 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

26. Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

1.

Risk for injury related to falling due to dizziness

2.

Client fell while walking to bathroom unassisted

3.

Client continues to report periods of dizziness upon sitting up

4.

Educated to the purpose of dangling on the bedside before standing

ANS: 4

The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention.

DIF: A REF: 391 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

27. Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

1.

His surgery corrected the mobility problem, so I draw a line through it and dated it.

2.

The clients problem list has several resolved problems on it; should I take them off?

3.

The client no longer has anxiety issues so I highlighted that problem on his problem list.

4.

He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list.

ANS: 4

New problems are added as they are identified. When a problem has been resolved, record the date and highlight it or draw a line through the problem and its number. Erasure is not an acceptable method of showing that a problem has been resolved.

DIF: A REF: 387 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

28. Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

1.

Risk for injury related to falling due to dizziness

2.

Client fell while walking to bathroom unassisted

3.

Client continues to report periods of dizziness upon sitting up

4.

Educated to the purpose of dangling on the bedside before standing

ANS: 1

The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention.

DIF: A REF: 385 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

29. Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

1.

Risk for injury related to falling due to dizziness

2.

Client fell while walking to bathroom unassisted

3.

Client continues to report periods of dizziness on sitting up

4.

Educated to the purpose of dangling on the bedside before standing

ANS: 4

The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention.

DIF: A REF: 390 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

MULTIPLE RESPONSE

1. Nursing documentation should fulfill which of the following criteria? (Select all that apply.)

1.

Accurate

2.

Inclusive

3.

Well organized

4.

Show continuity of care

5.

Record nursing opinion

6.

Identify client outcomes

ANS: 1, 2, 3, 4, 6

Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Nursing documentation should include nursing observations, not nursing opinions.

DIF: C REF: 390-391 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

2. The nurse realizes that effective nursing documentation encourages: (Select all that apply.)

1.

Safe nursing practice

2.

Continuity of client care

3.

Positive client outcomes

4.

Efficient time management

5.

Cost-conscious nursing care

6.

Effective nurse-client relationships

ANS: 1, 2, 4

Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors. While important, the remaining options are not criteria for effective nursing documentation.

DIF: C REF: 391 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

3. Problem Oriented Medical Record (POMR) method of documentation includes which of the following sections? (Select all that apply.)

1.

Database

2.

Care plan

3.

Evaluations

4.

Problem list

5.

Interventions

6.

Progress notes

ANS: 1, 2, 4, 6

The POMR has the following major sections: database, problem list, care plan, and progress notes. Interventions and evaluations are documentation sections related to PIE (Problem, Interventions, and Evaluation) charting.

DIF: A REF: 391 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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