Question 1

What key guidelines are generally accepted for documentation of nursing care? Select all that apply.

Accepted Answer

A)   Document what should be done.
B)   Documentation should be specific.
C)   Use direct quotes in documentation whenever possible.
D)   Documentation should be completed promptly.
E)   Document what you see.

Question 2

The nurse is reviewing a chart updated using the charting by exception format. Where would the nurse find the client's most recent lung sounds?

Accepted Answer

A)   Narrative notes
B)   Discipline area notes
C)   Flow sheets
D)   Problem-oriented list

Question 3

A nurse is caring for a client who is having an extended recovery period. Which intervention would be most effective in improving care for this client?

Accepted Answer

A)   Review the client's health record.
B)   Closely monitor the client's vital signs.
C)   Interact more frequently with the client.
D)   Identify simpler goals for the client.

Question 4

Which document would be most helpful in determining the client's ability to perform activities of daily living?

Accepted Answer

A)   Medical information systems (MIS) 
B)   Medical administration record (MAR) 
C)   Resident assessment protocol (RAP) 
D)   Charting by exception (CB
E)

Question 5

Which statement describes the purpose of progress records?

Accepted Answer

A)   Records all client information
B)   Guides nurses in the development of individualized care plans
C)   Provides access to the healthcare provider's orders and the nursing care plan
D)   Describes the treatment and responses of the client

Question 6

When considering documentation, what information should the nurse include on the client's MAR?

Accepted Answer

A)   Lists all the medications that the primary care provider has ordered for the client with spaces for the caregiver to mark when medications are given.
B)   Documents large amount of information collected at intervals over a specified period of time in brief, concise entries.
C)   At regular intervals, a summary of the client's condition or response to treatment is made.
D)   Summarizes an account of a client's relationship with a healthcare facility.

Question 7

During a change of shift reporting, a nurse has to substitute for the nurse who was primarily responsible for the care of a client. Which process would be most effective for the nurse's change-of-shift reporting?

Accepted Answer

A)   Use the clinical care path as the guide.
B)   Record any failure in achieving short-term goals.
C)   Prepare a written summary for the oncoming nurse.
D)   Report on specific nursing diagnosis.

Question 8

Which type of note does the nurse enter into the medical record at regular intervals to summarize the client's condition or response to treatment?

Accepted Answer

A)   SOAP
B)   Charting by exception
C)   Progress
D)   DARE

Question 9

Which data entry systems are examples of focus charting? Select all that apply.

Accepted Answer

A)   SOAP
B)   APIE
C)   PIE
D)   DARE
E)   SOAPIER

Question 10

Which statement entered into the medical record by the nurse is both objective and descriptive while demonstrating the principles of documentation?

Accepted Answer

A)   Client lonely
B)   Client out of touch with reality
C)   Client in pain
D)   Client rocking in chair

Question 11

Which is the correct abbreviation for before meals?

Accepted Answer

A)   AC
B)   BM
C)   IM
D)   PC A

Question 12

What is the meaning of the abbreviation "Ungt"?

Accepted Answer

A)   It is not an acceptable abbreviation
B)   Under the groin
C)   Ointment
D)   Undergarment C

Question 13

What client focused information should the nurse document in the client's manual health	 record?

Accepted Answer

A)   Long-term goals
B)   Vital signs
C)   Short-term goals
D)   Weekly progress status

Question 14

The nurse has to document information to maintain the health record of the client. Which nursing action is required for each charting entry?

Accepted Answer

A)   Reporting each observation to the healthcare provider.
B)   Signing the record with first initial, last name, and classification.
C)   Obtaining a signature from the primary care provider.
D)   Providing the day of the week on the entry.

Question 15

Why were apothecary units placed on the "do not use" list? Select all that apply.

Accepted Answer

A)   Misinterpreted because of similar abbreviations for multiple medications
B)   Unfamiliar to many practitioners
C)   Easily confused with metric units
D)   Commonly mistaken for the number two
E)   They are difficult to print

Question 16

Which statement accurately describes aspects of computerized charting?

Accepted Answer

A)   The system is relatively inexpensive to maintain.
B)   Bedside terminals eliminate the use of flow sheets and manual notes.
C)   The system provides speed and convenience for both entering and retrieving information.
D)   The system better protects client privacy than does conventional charting and storage methods.

Question 17

Which statement describes the best technique for identifying that a written error was made in a manual record sheet?

Accepted Answer

A)   Erase the incorrect statement and write the correct one.
B)   Cross out the incorrect statement with a single line.
C)   Cross out the wrong statement in a way that is not readable.
D)   Use correction ink to mark the wrong statement. B

Question 18

Which is the primary goal for maintaining a healthcare record for the client in particular?

Accepted Answer

A)   Meeting established legal requirements
B)   Documenting the ongoing health status of the client
C)   Verifying data for quality assurance program evaluations
D)   Providing information to be used as a resource for educational purposes

Question 19

A nurse is caring for a client in a healthcare facility who is about to be transferred to another healthcare facility for specialized care. Which data would be most helpful to ensure continuity of care?

Accepted Answer

A)   Transfer notes summarizing care.
B)   Referrals to community health services.
C)   Short-term goals to be achieved.
D)   Referrals to telephone consultation services.

Question 20

Which nursing interventions are helpful when considering the facility's need to be financially accountable? Select all that apply.

Accepted Answer

A)   Provide safe and effective healthcare to all clients.
B)   Ensure that the facility meets the governmental standards of care.
C)   Document all the treatments given to each client
D)   Verify the use of special equipment required to provide safe client care
E)   Record all billable services in the appropriate health records.

Exam 37: Documenting and Reporting

What key guidelines are generally accepted for documentation of nursing care? Select all that apply.

Correct AnswerverifiedShow Answer

The nurse is reviewing a chart updated using the charting by exception format. Where would the nurse find the client's most recent lung sounds?

Correct AnswerverifiedShow Answer

A nurse is caring for a client who is having an extended recovery period. Which intervention would be most effective in improving care for this client?

Correct AnswerverifiedShow Answer

Which document would be most helpful in determining the client's ability to perform activities of daily living?

Correct AnswerverifiedShow Answer

Which statement describes the purpose of progress records?

Correct AnswerverifiedShow Answer

When considering documentation, what information should the nurse include on the client's MAR?

Correct AnswerverifiedShow Answer

During a change of shift reporting, a nurse has to substitute for the nurse who was primarily responsible for the care of a client. Which process would be most effective for the nurse's change-of-shift reporting?

Correct AnswerverifiedShow Answer

Which type of note does the nurse enter into the medical record at regular intervals to summarize the client's condition or response to treatment?

Correct AnswerverifiedShow Answer

Which data entry systems are examples of focus charting? Select all that apply.

Correct AnswerverifiedShow Answer

Which statement entered into the medical record by the nurse is both objective and descriptive while demonstrating the principles of documentation?

Correct AnswerverifiedShow Answer

Which is the correct abbreviation for before meals?

Correct AnswerverifiedA

What is the meaning of the abbreviation "Ungt"?

Correct AnswerverifiedC

What client focused information should the nurse document in the client's manual health record?

Correct AnswerverifiedShow Answer

The nurse has to document information to maintain the health record of the client. Which nursing action is required for each charting entry?

Correct AnswerverifiedShow Answer

Why were apothecary units placed on the "do not use" list? Select all that apply.

Correct AnswerverifiedShow Answer

Which statement accurately describes aspects of computerized charting?

Correct AnswerverifiedShow Answer

Which statement describes the best technique for identifying that a written error was made in a manual record sheet?

Correct AnswerverifiedB

Which is the primary goal for maintaining a healthcare record for the client in particular?

Correct AnswerverifiedShow Answer

A nurse is caring for a client in a healthcare facility who is about to be transferred to another healthcare facility for specialized care. Which data would be most helpful to ensure continuity of care?

Correct AnswerverifiedShow Answer

Which nursing interventions are helpful when considering the facility's need to be financially accountable? Select all that apply.

Correct AnswerverifiedShow Answer

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C

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B

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