NCLEX practice questions documentation

NCLEX practice questions documentation

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CHAPTER 18: DOCUMENTING AND ...

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Documentation is:

• Anything written or printed that you rely on as record

or proof for authorized persons.

• Lab results for a patient you are taking care of.
• Admission paperwork for billing purposes.
• Instructions from the attending doctor.

A A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?

• The student nurse reviews the patient's medical record.
• The student nurse reads the patient's plan of care.
• The student nurse shares patient information with a

friend.

• The student nurse documents medication administered

to the patient

ANS: C

When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated. You can review your patients' medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient's medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit

Accreditation is:

• Certification by the ANA.
• Medicare approval.
• Joint Commission specifies guidelines for

documentation.

• Passing the NCLEX.

C

A nurse prepared an audiotaped exchange with another nurse of information about a patient.Which action did the nurse complete? The nurse completed a

• Report.
• Record.
• Consultation.
• Referral

ANS: A

Reports are oral, written, or audiotaped exchanges of information among caregivers. A patient's record or chart is a confidential, permanent legal document consisting of information relevant to his or her health care.Consultations are another form of discussion in which one professional caregiver gives formal advice about the care of a patient to another caregiver. Nurses document referrals (arrangements for the services of another care provider).Which of the following is correctly charted according to the six guidelines for quality recording?

A: "Was depressed today"

B:"respirations rapid; lung sounds clear"

C:"Had a good day. Up and about in room."

D:"Crying. States she does not want visitors to see her like

this"

D: reason you need to document pt. exact words in quotations when recording

subjective data.Explain the new rights for clients related to HIPPA.

• Patient right to leave healthcare facility.
• Patient education on privacy protections
• Patient's right to access their medical records.
• Provider must receive consent from patient before

releasing information.

• Recourse options if privacy protections are violated.

B, C, D, E

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records?

• The nurse determines the degree to which standards of

care are met by reviewing patients' health records.

• The nurse realizes that care not documented in

patients' health records still qualifies as care provided.

• The nurse knows that reimbursement is based on the

diagnosis-related groups documented in patients' records.

• The nurse compares data in patients' records to

determine whether a new treatment had better outcomes than the standard treatment.

ANS: A

The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring. The auditing/monitoring purpose involves nurses auditing records throughout the year to determine the degree to which standards of care are met and to identify areas needing improvement and staff development. The legal documentation purpose involves the concept that even though nursing care may have been excellent, in a court of law, "care not documented is care not provided." The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient's recorded findings to determine whether the new method was more effective than the standard protocol. Analysis of data from research contributes to evidence-based nursing practice and quality health care The standards of documentation by the Joint Commission

require:

• Narrative on how patient was cared for.
• Patient's vital signs every 4 hours.
• A resolution date for all planned outcomes.
• Documentation within the context of the nursing

process, as well as evidence of client and family teaching and discharge planning.D

After providing care, a nurse charts in the patient's record. Which entry should the nurse document?

• Appears restless when sitting in the chair
• Drank adequate amounts of water
• Apparently is asleep with eyes closed
• Skin pale and cool

ANS: D

A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, "B/P 80/50, patient diaphoretic, heart rate 102 and regular." Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as "Intake, 360 mL of water" is more accurate than "Patient drank an adequate amount of fluid."

If an error is made while recording, the nurse should:

A: erase it or scratch it out

B: leave a blank space in the note.

C: Draw a single line through the error and initial it

D: obtain a new nurse's note and rewrite the entries

C A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?

• "Patient seems to be in pain and states, 'I feel

uncomfortable.'"

• Status unchanged, doing well
• Left abdominal incision 1 inch in length without redness,

drainage, or edema

• Patient is hard to care for and refuses all treatments

and medications. Family present

ANS: C

Use of exact measurements establishes accuracy. Charting that an abdominal wound is "5 cm in length without redness, drainage, or edema" is more descriptive than "large wound healing well." Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as "status unchanged" or "had a good day." It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions."Patient is hard to care for" is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, "Refuses all treatments and medications."

Define Client record:

• A confidential, permanent legal documentation of

information relevant to a client's health care.

• Name, address, phone number, insurance information.
• List of medications.
• Temporary notes made pertaining to the clients

current visit made on the nurses pocket notepad.A

Define reports:

• Oral, written, or audiotaped exchanges between

caregivers.

• Summary of xrays, MRI and Sonograms done on

patient.

• Documentation of all activity patient has had

previously for current condition.

• Review of all patients for cause trending.

A A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to intervene?

• The new nurse uses a black ink pen to chart.
• The new nurse charts consecutively on every other line.
• The new nurse ends each entry with signature and title.
• The new nurse keeps the password secure

ANS: B

Chart consecutively, line by line (not every other line); if space is left, draw a line horizontally through it, and sign your name at the end. Every other line should not be left blank. Record all entries legibly and in black ink. End each entry with your signature and title. For computer documentation, keep your password to yourself.Using black ink, ending each entry with signature and title, and keeping the password secure are all appropriate behaviors

Define consultations:

• Lab results
• End of shift transition to next shift
• Form of discussion whereby one professional

caregiver gives formal advice about the level of care of a client to another caregiver.

• Indication by billing on patients ability to pay.

C A nurse is charting on a patient's record. Which action is most accurate legally?

• Charts legibly
• States the patient is belligerent
• Uses correction fluid to correct error
• Writes entry for another nurse

ANS: A

Record all entries legibly. Do not write personal opinions. Enter only objective and factual observations of patient's behavior; quote all patient comments. For example, patient refuses to cough and deep breathe, saying, "I don't care what you say, I will not do it." Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself

Define Referrals:

• A physicians order for lab work
• An arrangement for services by another care provider
• Any physicians order that requires a authorization from

the insurance company.

• Treatment options the physician discusses with the

patient.B A nurse wants to integrate all pertinent patient information into one record, regardless of the number of times a patient enters the health care system.Which term should the nurse use to describe this system?

• Electronic medical record
• Electronic health record
• Electronic charting record
• Electronic problem record

ANS: B

A unique feature of an electronic health record (EHR) is its ability to integrate all pertinent patient information into one record, regardless of the number of times a patient enters a health care system. Although the electronic medical record (EMR) contains patient data gathered in a health care setting at a specific time and place and is a part of the EHR, the two terms are frequently used interchangeably. There are no such terms as electronic charting record or electronic problem record Match the correct entry with the appropriate SOAP category. 1=S 2=O 3=A 4=P

A: Repositioned pt on right side. Encouraged pt to use

patient-controlled analgesia device

B: "the pain increases every time I try to turn on my left

side"

C: Acute pain related to tissue injury from surgical incision

D: left lower abdominal surgical incision, 3 inches in

length, closed, sutures intact, no drainage. Pain noted on mild palpation

1=B 2=D 3=C 4=A

Define "Education".

• Nursing giving a patient a pamplet about various

health conditions.

• Smoking cessation classes
• Learning the nature of an illness and the individual

client's responses

• Nursing care in local schools with school aged

children.C