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?
Instructions given to the client in a teaching plan.
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?
The witnessing nurse completes the report.
Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?
0830--increased IV fluid rate to 100 ml/hr according to protocol.
The nurse makes a late entry in a client's record. Which of the following is the best example of how to document this type of situation?
"2;45 pm -- ASA gr X given for temperature 38.1 'C."
The following statement: " upon exertion, the client is wheezing and experiencing some dyspnea," is an example of :
the 'P" of PIE
To loate the recording of a nurse's description of the teaching provided to the client on performance of self-medication administration, one would look in a
Discharge summary form
The nurse has made an error and is documenting such on the client's record and notes. The action that the nurse should take is to:
Draw a straight line through the error and initial it.
The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes there is evidence of appropriate docmentation when the new staff nurse:
Dates and signs all of the entries made in the record.
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.
"Let me get the Registered Nurse on the phone."
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?
'My arm feels better'
Which of the following is evaluated as a legally appropriate notation?
Verbalized sharp, stabbing pain along the left side of the chest.
To avoid legal risks and possible lack of confidentiality associated with computerized documentation many programs currently have
Periodic changes in staff passwords
Which of the following nursing statements reflects the best understanding of the role of documentation and the medicare reimbursement policy?
"The hospital is reinbursed for the nursing care documented in the client chart"
The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, or treatment:
Which of the following nursing statements regarding the release of a client's medical record to another institution requires immediate follow-up by the nurse's manager?
"The client agreed to the consultation, so i'll have the chart sent over."
Regarding access to client records, the nursing faculty informs the nursing students to be prepared to;
Show the unit staff proper student identification
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?
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:
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