Which action by a nurse ensures confidentiality of a client's computer
record?
1. The nurse logs on to the client's file and leaves the computer to answer the client's call light.
2. The nurse shares her computer password.
3. The nurse closes a client's computer file and logs off.
4. The nurse...
Rationale: Critical pathways work best for clients with one diagnosis.
After making a documentation error, which action should the nurse take?
1. Use correcting liquid to cover the mistake and make a new entry.
2. Draw a line through it and write error above the entry.
3. Draw a line through it and write mistaken entry above it.
4. Draw a line through the mistake and write mistaken entry with initials above it - ✔✔✔Answer: 4
Rationale: It is the most complete answer. The client's record is a legal record and should not be altered
with correcting liquid. You may see "error" written above a mistake even though many authors suggest
not writing it. It is important to also put your name or initials next to the words of the mistaken entry.
, During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks
that the client's blood pressure (BP) seems high. What is the next step?
1. Ask the client about past blood pressure ranges.
2. Review the graphic record on the client's record.
3. Examine the medication record for antihypertensive
medications.
4. Review the progress notes included in the client's record. - ✔✔✔Answer: 2
Rationale: The graphic record provides the trend of the vital signs. Option 1, verbal information, is not
appropriate for validation assessment that is measurable. This is more appropriate for pain
or dizziness. The medication record would not include documentation of blood pressure ranges (option
3). The progress notes (option 4) provide information about how the client is progressing. It may have
information about the client's BP if it was a problem. The best answer is option 2.
A student nurse observes the change-of-shift report. Which behavior(s) by the reporting nurse
represents effective nursing practice? Select all that apply.
1. Provides the medical diagnosis or reason for admission.
2. States the time the client last received pain medication.
3. Speaks loudly when giving report.
4. States priorities of care that are due shortly after the report.
5. Reports on number of visitors for each client. - ✔✔✔Answer: 1, 2, and 4
Rationale: Option 3 is incorrect because it could
be a HIPAA violation if others hear protected health information. Option 5 is not needed unless it is a
concern and it would not be done for every client.
Which charting entries are written correctly? Select all that apply.
1. MS 5 gr given IV for c/o abdominal pain
2. Lanoxin 0.25 mg given orally per Dr. Smith's stat order
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller jessyqueen. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.73. You're not tied to anything after your purchase.
