10TYK. Which charting rule(s) will keep the nurse legally safe? Select all that apply.
1. Use military time.
2. Document worries or concerns expressed by the client.
3. Perform most of the charting at the end of the shift.
4. Record only information that pertains to the client’s health problems.
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1CTC. Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8—Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
What guidelines were not used in this documentation?
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1TYK. 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 leaves client computer worksheets at the computer workstation.
Get Solution
2CTC. Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8—Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
The nursing diagnosis for Mr. Anderson is Acute Pain. What would you expect to document?
Get Solution
2TYK. The case management model using critical pathways would be appropriate for a client with which diagnosis?
1. Myocardial infarction (heart attack)
2. Diabetes, hypertension
3. Myocardial infarction, diabetes, hypertension
4. Diabetes, hypertension, an infected foot ulcer, senile dementia
Get Solution
3CTC. Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8—Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
Sort the following pieces of data for Mr. Anderson into a SOAP note:
a. "I didn’t sleep last night”
b. Positioned on side with pillows behind back
c. Continues to need narcotic medication to progress toward goal of pain relief
d. States pain is 8 out of 10
e. “I feel better” (after interventions)
f. Last medicated 5 hours previously
g. Heating pad applied to lower back
h. BP 210/90, P 72, R 18
i. Add to plan of care to offer analgesic around the clock q4h versus pm j. 6/6/15 #1 Pain
k. “Sharp, stabbing pain in lower back that radiates to left leg”
I. Medicated with ordered analgesic
Get Solution
3TYK. 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.
Get Solution
4CTC. Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8—Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
Sort the pieces of data from Question 3 into a DAR note.
Get Solution
4TYK. Which charting entry would be the most defensible in court?
1. Client fell out of bed
2. Client drunk on admission
3. Large bruise on left thigh
4. Notified Dr. Jones of BP of 90/40
Get Solution
5TYK. The client’s VS are WNL. He has BRP and he receives his pain pill PRN. His nutrition is DAT Interpret the commonly used abbreviations.
1. NKA:____________________
2. BRP:____________________
3. PRN;____________________
4. DAT:____________________
Get Solution
6TYK. 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.
Get Solution
7TYK. 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.
Get Solution
8TYK. 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
3. KC115 mL given orally for K+ level of 2.9
4. Regular insulin 10.0 u given SQ for capillary blood glucose of 180
Ambien 5 mg given orally at bedtime per request
Get Solution
9TYK. A 74-year-old female is brought to the emergency department c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appears to be cigarette burns on the client’s inner thighs. Which of the following is the most appropriate documentation?
1. Six round skin lesions partially healed, on the inner thighs bilaterally
2. Several burned areas on both of the client’s inner thighs
3. Multiple lesions on inner thighs possibly related to elder abuse
4. Several lesions on inner thighs similar to cigarette burns
Get Solution
1. Use military time.
2. Document worries or concerns expressed by the client.
3. Perform most of the charting at the end of the shift.
4. Record only information that pertains to the client’s health problems.
Get Solution
1CTC. Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8—Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
What guidelines were not used in this documentation?
Get Solution
1TYK. 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 leaves client computer worksheets at the computer workstation.
Get Solution
2CTC. Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8—Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
The nursing diagnosis for Mr. Anderson is Acute Pain. What would you expect to document?
Get Solution
2TYK. The case management model using critical pathways would be appropriate for a client with which diagnosis?
1. Myocardial infarction (heart attack)
2. Diabetes, hypertension
3. Myocardial infarction, diabetes, hypertension
4. Diabetes, hypertension, an infected foot ulcer, senile dementia
Get Solution
3CTC. Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8—Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
Sort the following pieces of data for Mr. Anderson into a SOAP note:
a. "I didn’t sleep last night”
b. Positioned on side with pillows behind back
c. Continues to need narcotic medication to progress toward goal of pain relief
d. States pain is 8 out of 10
e. “I feel better” (after interventions)
f. Last medicated 5 hours previously
g. Heating pad applied to lower back
h. BP 210/90, P 72, R 18
i. Add to plan of care to offer analgesic around the clock q4h versus pm j. 6/6/15 #1 Pain
k. “Sharp, stabbing pain in lower back that radiates to left leg”
I. Medicated with ordered analgesic
Get Solution
3TYK. 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.
Get Solution
4CTC. Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8—Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
Sort the pieces of data from Question 3 into a DAR note.
Get Solution
4TYK. Which charting entry would be the most defensible in court?
1. Client fell out of bed
2. Client drunk on admission
3. Large bruise on left thigh
4. Notified Dr. Jones of BP of 90/40
Get Solution
5TYK. The client’s VS are WNL. He has BRP and he receives his pain pill PRN. His nutrition is DAT Interpret the commonly used abbreviations.
1. NKA:____________________
2. BRP:____________________
3. PRN;____________________
4. DAT:____________________
Get Solution
6TYK. 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.
Get Solution
7TYK. 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.
Get Solution
8TYK. 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
3. KC115 mL given orally for K+ level of 2.9
4. Regular insulin 10.0 u given SQ for capillary blood glucose of 180
Ambien 5 mg given orally at bedtime per request
Get Solution
9TYK. A 74-year-old female is brought to the emergency department c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appears to be cigarette burns on the client’s inner thighs. Which of the following is the most appropriate documentation?
1. Six round skin lesions partially healed, on the inner thighs bilaterally
2. Several burned areas on both of the client’s inner thighs
3. Multiple lesions on inner thighs possibly related to elder abuse
4. Several lesions on inner thighs similar to cigarette burns
Get Solution
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