Documentation Practice for NCLEX Questions 4.0 (4 reviews) Students also studied Terms in this set (10) Science MedicineNursing Save NCLEX practice questions documen...88 terms mabusnealPreview
CHAPTER 18: DOCUMENTING AND ...
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- A nurse is documenting patient data in the medical
- 6/12/15 0945 Morphine 10 mg administered IV. Patient's
- 6/12/15 0945 Morphine 10 mg administered IV. Patient
- 6/12/15 0945 30 minutes following administration of
- to 10. M. Patrick, RN
- 6/12/15 0945 Patient reports severe pain in right lower
- 6/12/15 0945 Morphine IV 10 mg will be administered to
- 6/12/15 0945 Patient states she does not want pain
- 6/12/15 0945 30 minutes following administration of morphine 10 mg IV patient
- 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN
- 6/12/15 0945 Patient states she does not want pain medication despite return of
record of a patient admitted to the hospital with a diagnosis of appendicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines? Select all that apply.
response to pain appears to be exaggerated. M. Patrick, RN
seems to be comfortable. M. Patrick, RN
morphine 10 mg IV patient reports pain as 2 on a scale of
quadrant. M. Patrick, RN
patient every 3 to 4 hours. M. Patrick, RN
medication despite return of pain. After discussing situation, patient agrees to medication administration.
reports pain as 2 on a scale of 1 to 10. M. Patrick, RN
pain. After discussing situation, patient agrees to medication administration.
- A nurse is documenting the care given to a 56-year-old
- Erase or use correcting fluid to completely delete the
- Draw a single line through the entry and rewrite it
- Use a permanent marker to block out the mistaken
- Remove the page with the error and rewrite the data
- Draw a single line through the entry and rewrite it above or beside it.
- A nurse is discharging a patient from the hospital
- "I'm sorry, but patients are not allowed to copy their
- "I can make a copy of your record for you right now."
- "You can read your record while you are still a patient,
patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation?
error.
above or beside it.
entry and rewrite it.
on that page correctly.
following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response?
medical records."
but copying records is not permitted according to HIPAA rules." d ."I will need to check with our records department to get you a copy." d ."I will need to check with our records department to get you a copy."
- According to the Health Insurance Portability and
- News media are preparing a report on the condition of
- Data are needed for the tracking and notification of
- Protected health information is needed by a coroner.
- Child abuse and neglect are suspected.
- Protected health information is needed to facilitate
- The sister of a patient with Alzheimer's wants to help
- Data are needed for the tracking and notification of disease outbreaks.
- Protected health information is needed by a coroner.
- Child abuse and neglect are suspected.
- Protected health information is needed to facilitate organ donation.
- A friend of a nurse calls and asks if she is still working
- "You shouldn't be asking me to do this. I could be fined
- "Sorry, but I'm not able to give information about
- "Because of the Health Insurance Portability and
- "Why do you think Sue isn't talking about her worries?"
- "Sorry, but I'm not able to give information about patients to the public—even
Accountability Act of 1996, if a health institution wants to release a patient's health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed? Select all that apply.
a public figure.
disease outbreaks.
organ donation.
provide care.
at Memorial Hospital. The nurse replies, "Yes." The friend tells the nurse that his girlfriend's father was just admitted as a patient and he wants the nurse to find out how he is.The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make?
or even lose my job for disclosing this information."
patients to the public—even when my best friend or a family member asks."
Accountability Act, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!"
when my best friend or a family member asks."
- A patient has an order for an analgesic medication to
- Every three hours
- Every four hours
- Daily
- As needed
- As needed
- A resident who is called to see a patient in the middle
be given PRN. When would the nurse administer this medication?
of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the
physician's order sheet. The nurse's best response is:
- "Thank you for taking care of this!"
- Get a second nurse to listen to the order, and after
- "I am sorry, but verbal orders can only be given in an
- Try calling another resident for the order or wait until
- "I am sorry, but verbal orders can only be given in an emergency situation that
- A nurse is looking for trends in a postoperative patient's
- Admission sheet
- Admission nursing assessment
- Activity flow sheet
- Graphic record
- Graphic record
writing the order on the physician order sheet, have both nurses sign it.
emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly."
the next shift.
prevents us from writing them out. I'll bring the chart and we can do this quickly."
vital signs. Which documents would the nurse consult first?