nursing process/documentation cont – Flashcards

DESCRIBE THE NURSING PROCESS

a patient with a urinary tract infection which is assessed using a clinical pathway. when a projected outcome is not met by a predetermined date what has occurred

a nurse educating a student nurse about documentation the nurse realizes further education is needed if the patient states

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

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

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: 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.

. 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

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"

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? 1. "I'm pretty sure this will require the client's permission." 2. "Are you sure of the exact policy? Do you know what I should do?" 3. "The client agreed to the consultation, so I'll have the chart sent over." 4. "I think the client will need to give a verbal consent before it can be sent."

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

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 client's continued attempts to smoke in the bathroom

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

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