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PNU 116 PrepU Chapter 19 Documenting and Reporting Exam
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PNU 116 PrepU Chapter 19 Documenting andReporting Exam
The nurse manager and a nurse are discussing a social media posting by the nurse
regarding an interesting client situation. The nurse says, "I did not violate client privacy
because I did not use the client's name." The most appropriate response by the nurse
manager would be: - ANSWER "Any information that identifies a person is a breach of
client privacy."
The nurses in the health care facility are informed that the clients' records are to be
planned into problem-oriented records. Which explanation may help the nurses make a
decision on the benefit of using problem-oriented records? - ANSWER Problem-oriented
recording emphasizes goal-directed care to promote the recording of pertinent data
that will facilitate communication among health care providers.
The parents of a hospitalized 10-year-old ask the nurse whether they can review the
health care record of their child. What is the most appropriate response by the nurse? -
ANSWER "I will arrange access for you to review the record after you put your request
in writing."
The client requests, in writing, to see his or her medical record. He or she reviews it and
then tells the nurse that he or she believes there are errors on the medical record. What
is the most appropriate nursing response? ANSWER "According to HIPAA legislation
you have a right to request changes to inaccurate information."
Which of the following nurse-to-provider communication appropriately applies the SBAR
format to improve communication? - ANSWER "I am calling about Mr. Jones. He has new
onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I
wondered if you would like to adjust the sliding scale insulin."
The nurse calls the health care provider due to changes in the client's status. Utilizing
the SBAR, the nurse is about to address Recommendation. Which statement supports
this part of the SBAR? ANSWER "Will you order a complete blood count to evaluate the
, white blood cell count and a culture?
A nurse is working within the case management model and using a collaborative
pathway. The nurse identifies that the client has not achieved an expected outcome and
records this through the use of occurrence charting. When the nurse completes this
charting, which of the following information would the nurse include? - ANSWER
Unexpected event
Cause of the event
Actions taken as a result of the event
The client is to undergo CABG. Which information should the nurse give to the client? -
ANSWER "A coronary artery bypass graft will benefit your heart."
A nurse is transfusing multiple units of packed red blood cells. After the second unit is
transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs
and the client reports dyspnea. The nurse telephones the health care provider and
provides an SBAR report. Which statement represents the final step in this type of
communication? - ANSWER "I think the client would benefit from intravenous
furosemide."
The nurse is re-documenting on a client who has received pain medication to help
manage pain related to a bilateral knee replacement. Which statement best describes
appropriate documentation of pain assessment? - ANSWER The client rates the current
pain as 3 out of 10.
Which statement regarding client records and documentation is true? - ANSWER The
purpose of client records is for communication.
Medication Order A nurse has administered 1 unit of glucose to the client as ordered.
Which documentation of the following is accurate regarding this action? - ANSWER 1
Unit of glucose
Medication Abbreviation A new graduate is working at a first job. Which of the following
statements is most appropriate for the new nurse to follow? - ANSWER Use
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