Ramont2e Rev TIF Ch14

8/20/2019 Ramont2e Rev TIF Ch14

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 14Question 1

Type: MCSA

The nurse’s responsibility(ies) in client charting include(s)

1. Ethical obligations

2. Legal obligations

. Legal and ethical obligations

4. Educational obligation

Corre!t "ns#er: 3

Rationa$e 1: Ethical obligations include respecting human dignity client pri!acy and client needs" This is not the

only obligation"

Rationa$e 2: Legal obligations include accurate and timely recording and maintaining client pri!acy" This is not

the only obligation"

Rationa$e : Ethical obligations include respecting human dignity client pri!acy and client needs" Legal

obligations include accurate and timely recording and maintaining client pri!acy"

Rationa$e 4: Educational obligations are not the nurses’ main responsibility in documenting client care and

progress"

%$o&a$ Rationa$e:

Cogniti'e (e'e$: #nderstanding

C$ient Need: Sa$e E$$ecti!e Care En!ironment

C$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: &lanning

(earning ut!ome:

Question 2

Type: MCMA

The nurse documents client care remembering that the $ollo'ing guidelines must be $ollo'ed:

)tandard Te-t: Select all that apply"

1. Each entry must be dated and timed per agency policy

amont %iedringhous Comprehensive Nursing Care nd Edition #pdate Test *an+

Copyright ,- by &earson Education .nc"



2. ecord care be$ore it is pro!ided per agency policy

. Ma+e all entries in blue or blac+ in+

4. #se only accepted abbre!iations and symbols

. Spell medication names correctly to a!oid medication errors

Corre!t "ns#er: -3/0

Rationa$e 1: Each entry needs to include the date and time the note is 'ritten and needs to be made as soon as

possible a$ter per$orming a nursing action"

Rationa$e 2: ecording care be$ore it is pro!ided is unethical and illegal"

Rationa$e : #se only blue or blac+ indelible in+ per agency policy"

Rationa$e 4: #se only abbre!iations that are appro!ed by the agency1 i$ in doubt spell the 'ord out"

Rationa$e : Spelling medication names 'ill decrease the possibility o$ medication errors"

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Applying


C$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: .mplementation

(earning ut!ome:

Question

Type: MCMA

The nurse a!oids errors in documentation by $ollo'ing accepted guidelines 'hen documenting in a client record

'hich include:


1. 2escribe 'hat you thin+

2. uote client directly

. 2escribe obser!ed beha!ior

4. Lea!e spaces bet'een entries per agency policy

. 4rite error through a mista+en entry

Corre!t "ns#er: 3





Rationa$e 1: An accurate entry records 'hat the nurse sees and hears not thoughts or opinions"

Rationa$e 2: uoting client directly 'ill ensure that client’s concerns are recorded correctly"

Rationa$e : 2escription o$ obser!ed beha!ior such as crying is more accurate than the nurse’s interpretation o$

'hat the beha!ior means such as an5iety"

Rationa$e 4: 4rite on e!ery line but ne!er bet'een lines" Lea!ing a space could allo' $or ma+ing a late entry by

another person"

Rationa$e : Correct an error by dra'ing a single line through the error and 'riting the 'ord error abo!e it"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 4

Type: MCSA

The nurse records care o$ a client 'ho is medicated $or pain" The most accurate entry 'ould be:

1.

2.

.

4.

Corre!t "ns#er:

Rationa$e 1: Assessments inter!entions and client responses are recorded in the order in 'hich they occur" E!eryinter!ention needs an e!aluation to be considered complete

Rationa$e 2: Assessments inter!entions and client responses are recorded in the order in 'hich they occur" E!ery

inter!ention needs an e!aluation to be considered complete" .n addition the nurses recorded the client’s statemen

Rationa$e : Assessments inter!entions and client responses are recorded in the order in 'hich they occur" E!ery

inter!ention needs an e!aluation to be considered complete" The initial entry did not include an e!aluation o$e$$ecti!eness"

Rationa$e 4: Assessments inter!entions and client responses are recorded in the order in 'hich they occur" E!ery

inter!ention needs an e!aluation to be considered complete" Site o$ pain 'as not included in this entry so another

healthcare pro$essional 'ould not +no' i$ 'here the pain originated"





%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question Type: MCMA

Accurate complete and appropriate nursing entries in a client chart include:


1. (date) ,,, Mrs" Smith appears to be sleeping"666666S" Smith L&%

2. (date) ,,, Client resting in bed 'ith eyes closed"666666S" Smith L&%

. (date) ,7,, Client angry at husband $or spending too much money" 6666666S" Smith L&%

4. (date) ,8,, Client re$used ,/,, dose o$ Amo5acillin"6666666S" Smith L&%

. (date) ,9,, Client smiling tal+ing on telephone" 66666S" Smith L&%

Corre!t "ns#er: 0

Rationa$e 1: The 'ord appears’ ma+es the entry an interpretation rather than an obser!ation"

Rationa$e 2: This entry describes 'hat the nurse obser!ed"

Rationa$e : This entry interprets the client’s actions or 'ords" A more accurate entry 'ould be: (date) ,7,,

Client tal+ing on phone 'ith loud !oice" Stated ;ho' could you spend the mortgage money on a car<= Client

stated that she 'as tal+ing to her husband"6666S" Smith L&%"

Rationa$e 4: This entry is not appropriate as it is $i!e hours a$ter the medication 'as re$used and does not includ;late entry="

Rationa$e : This entry describes 'hat the nurse obser!ed"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:





Question /

Type: MCSA

4hen accessing a client’s record the nursing student is care$ul to

1. #se the instructors pass'ord

2. Turn the monitor around 'hen 'al+ing a'ay $rom the computer

. Lea!e notes and in$ormation in the $acility’s receptacle $or papers containing &>. 'hen $inished $or the day

4. Allo' only the client’s $amily to see the notes

Corre!t "ns#er: 3

Rationa$e 1: &ass'ords $or electronic medical records should not be shared"

Rationa$e 2: The student should sign out o$ the computer 'hen lea!ing the terminal"

Rationa$e : All material 'ith &>. (protected health in$ormation) should be le$t at the $acility and care plansshould only include initials to protect client con$identiality"

Rationa$e 4: The nurse should not allo' access to a client’s record by signi$icant others or any other person otherthan the healthcare pro!iders 'ho are directly in!ol!ed in the care o$ the client"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 0

Type: MCMA

4hen correcting an incorrect entry or posting late entry in an electronic medical record the nurse:


1. .ndicates the reason $or the correction

2. .denti$ies the entry as a late entry

. Enters the date the entry should ha!e been made

4. Sign the entry





. 2ocument the late entries as soon as possible

Corre!t "ns#er: -0

Rationa$e 1: The corrected entry should be labeled ;'rong patient= or other appropriate terminology"

Rationa$e 2: Late entries need to be labeled as such"

Rationa$e : Late entries need to be dated 'ith the date the entry is being made"

Rationa$e 4: The entry needs to be signed per agency protocol"

Rationa$e : Late entries need to be entered as soon as possible1 the longer the time lapse the less reliable the

entry becomes"

%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: %ursing &rocess: .mplementation

(earning ut!ome:

Question

Type: MCMA

#nderstanding the nursing process is essential to 'hich o$ the $ollo'ing types o$ documentation methods:


1. &.E charting

2. A&.E charting

. C?E 2AE documentation system

4. S?A& charting

. C*E

Corre!t "ns#er: -3

Rationa$e 1: &.E charting (problem inter!ention e!aluation) is based on the nursing process"

Rationa$e 2: A&.E charting (assessment problem inter!ention e!aluation) is based on the nursing process"

Rationa$e : C?E 2AE documentation system $ocuses on the nursing process1 it consists o$ a database plans ocare $lo' sheets progress notes discharge summary1 2AE stands $or data action e!aluation"





Rationa$e 4: S?A& charting (sub@ecti!e data ob@ecti!e data assessment planning) is o$ten oriented around a problem list"

Rationa$e : C*E (charting by e5ception) is a documentation system in 'hich only signi$icant $indings or

e5ceptions to norms are recorded1 C*E includes uniue $lo' sheets documenting by re$erence to agency’s

printed standards o$ nursing practice1 documentation $orms at the bedside $or immediate recording"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCSA

The nurse 'ho 'or+s in a $acility that is changing $rom a source oriented system o$ documentation to the BACT

system o$ documentation 'ill disco!er the main di$$erence bet'een the t'o is

1. The BACT system duplicates in$ormation

2. The source oriented system duplicates in$ormation

. The BACT system documents progress in 2AE $ormat

4. The BACT system is similar to C*E and is designed to eliminate redundant and irrele!ant data

Corre!t "ns#er: /

Rationa$e 1: The BACT system is consists o$ $lo' sheets that are indi!idualied assessment sheet that is

standardied concise integrated progress notes and $lo' sheets timely entries and is computer ready" .t is

e$$icient and time sa!ing"

Rationa$e 2: The source oriented system tends to ha!e duplication o$ in$ormation as e!ery caregi!er ma+esentries in di$$erent parts o$ the record"

Rationa$e : The BACT system does not use the data action e!aluation $ormat o$ progress notes"

Rationa$e 4: The BACT system is named $or its elements and is designed to eliminate redundant and irrele!antdata and inconsistencies in recording"

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Analying


C$ient Need )u&:






(earning ut!ome:

Question 13

Type: MCMA

The L&%DL% is gi!ing change o$ shi$t report to the oncoming nurse" eport on the client 'ho has @ust been

admitted $rom the emergency room $or an asthma attac+ should include:


1. %ame age room number

2. List o$ client’s problems

. isitors 'ho ha!e seen client including clergy

4. >ead to toe re!ie'

. Medication list

Corre!t "ns#er: -/

Rationa$e 1: eport on ne'ly admitted clients should include diagnosis age general condition plan o$ therapy

in$ormation about client’s support people"

Rationa$e 2: A current problem list including priorities and changes in condition during the shi$t should beincluded"

Rationa$e : Coming and going o$ !isitors is not included unless there is a problem or concern"


in$ormation about client’s support people"

Rationa$e : Current medication list $or a ne' admission 'ill be o$ interest to ma+e sure continuity is maintained

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 11

Type: MCSA





4hen e5plaining the purpose and characteristics o$ reporting to the ne' graduate the nurse summaries the

common $eatures as

1. .ndi!idualied

2. Concise

. 4ritten

4. S*A $ormat

Corre!t "ns#er:

Rationa$e 1: eporting may be gi!en to a group o$ nurses or to the nurse ta+ing o!er the nurse’s assigned clients"

Rationa$e 2: A report should be concise including pertinent in$ormation but should not include any e5traneousdetail"

Rationa$e : eporting may be 'ritten or oral

Rationa$e 4: S*A $ormat (Situation bac+ground assessment recommendation) is a $ormat that is use$ul in

many reporting situations but is not common to all reporting $ormats

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 12

Type: MCSA

4hen con$irming telephone orders or other communication the L&%DL% documents

1. Telephone order recei!ed by

2. erbal order recei!ed by

. Agency protocol

4. -,,F read bac+

Corre!t "ns#er: /

Rationa$e 1: %ot all telephone communication in!ol!es orders1 it may in!ol!e laboratory in$ormation"





Rationa$e 2: %ot all telephone communication in!ol!es orders1 it may in!ol!e laboratory in$ormation"

Rationa$e : Agency protocol should concur 'ith regulatory agency policy"

Rationa$e 4: The Goint Commission reuires that any in$ormation gi!en o!er the phone be repeated to the caller

and documented as ;-,,F read bac+"="

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCMA

The student nurse is attending a nursing care con$erence" Characteristics o$ the nursing care con$erence include:


1. 2iscuss possible solutions to a client problem

2. 4or+ing together as a group to create a plan o$ care

. Climate o$ respect

4. 2iscussion o$ nursing unit issues

. Listening to others’ idea

Corre!t "ns#er: -3

Rationa$e 1: The goal o$ the nursing care con$erence is to discuss possible solutions to certain client problems"

Rationa$e 2: %urses 'or+ together as a group to create a plan o$ care that is consistent"

Rationa$e : %urses 'or+ and communicate 'ith a climate o$ respect"

Rationa$e 4: 2iscussion o$ other issues on the nursing unit is not appropriate at this time"

Rationa$e : The nurses at a care con$erence listen to each others’ ideas 'ith an open mind to $ind a solution $or

the client problem"

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 14

Type: MCMA

The L&%DL% 'ill o$ten be responsible $or completing the discharge note or re$erral summary" The in$ormationto be documented includes:


1. esol!ed health problems

2. Continuing health problems

. Treatments that ha!e been completed

4. Sel$6care abilities

. Current medications

Corre!t "ns#er: -/0

Rationa$e 1: esol!ed health problems need to be included as part o$ the database"

Rationa$e 2: Continuing health problems and care needs must be included $or appropriate $ollo'6up care"

Rationa$e : Treatments that are not to be continued are unnecessary to report"

Rationa$e 4: Sel$6care and $unctional abilities including !ision hearing etc" should be reported to the recei!ingcare $acility"

Rationa$e : Current medications need to be included in the report so that important therapies are not interrupted

%$o&a$ Rationa$e:




(earning ut!ome:

Question 1

Type: MCSA

The nurse’s responsibilities in client charting include:





1. Ethical obligations"

2. Legal obligations"

. Legal and ethical obligations"

4. Educational obligations"

Corre!t "ns#er: 3

Rationa$e 1: Ethical obligations include respecting human dignity client pri!acy and client needs" This is not the

only obligation"

Rationa$e 2: Legal obligations include accurate and timely recording and maintaining client pri!acy" This is notthe only obligation"

Rationa$e : Ethical obligations include respecting human dignity client pri!acy and client needs" Legal

obligations include accurate and timely recording and maintaining client pri!acy"

Rationa$e 4: Educational obligations are not the nurses’ main responsibility in documenting client care and progress"

%$o&a$ Rationa$e:

Cogniti'e (e'e$: #nderstanding


C$ient Need )u&:


(earning ut!ome:

Question 1/Type: MCMA

The nurse documents client care remembering that the $ollo'ing guidelines must be $ollo'ed:


1. Each entry must be dated and timed per agency policy"

2. ecord care be$ore it is pro!ided per agency policy"

. Ma+e all entries in blue or blac+ in+"

4. #se only accepted abbre!iations and symbols"

. Spell medication names correctly to a!oid medication errors"

Corre!t "ns#er: -3/0





Rationa$e 1: Each entry needs to include the date and time the note is 'ritten and needs to be made as soon as possible a$ter per$orming a nursing action"

Rationa$e 2: ecording care be$ore it is pro!ided is unethical and illegal"

Rationa$e : #se only blue or blac+ indelible in+ per agency policy"

Rationa$e 4: #se only abbre!iations that are appro!ed by the agency1 i$ in doubt spell the 'ord out"

Rationa$e : Spelling medication names 'ill decrease the possibility o$ medication errors"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 10Type: MCMA

The nurse a!oids errors in documentation by $ollo'ing accepted guidelines 'hen documenting in a client record'hich include:


1. 2escribe 'hat you thin+"

2. uote the client directly"

. 2escribe obser!ed beha!ior"

4. Lea!e spaces bet'een entries per agency policy"

. 4rite through a mista+en entry"

Corre!t "ns#er: 3

Rationa$e 1: An accurate entry records 'hat the nurse sees and hears not thoughts or opinions"

Rationa$e 2: uoting the client directly 'ill ensure that the client’s concerns are recorded correctly"

Rationa$e : 2escription o$ obser!ed beha!ior such as crying is more accurate than the nurse’s interpretation o$'hat the beha!ior means such as an5iety"

Rationa$e 4: 4rite on e!ery line but ne!er bet'een lines" Lea!ing a space could allo' $or another person’s

ma+ing a later entry"





Rationa$e : Correct an error by dra'ing a single line through the error and 'riting the 'ord error abo!e it"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCMA

Accurate complete and appropriate nursing entries in a client chart include:


1. (date) ,,, Mrs" Smith appears to be sleeping"666666S" Smith L&%

2. (date) ,,, Client resting in bed 'ith eyes closed"666666S" Smith L&%

. (date) ,7,, Client angry at husband $or spending too much money" 6666666S" Smith L&%

4. (date) ,8,, Client re$used ,/,, dose o$ Amo5icillin"6666666S" Smith L&%

. (date) ,9,, Client smiling tal+ing on telephone" 66666S" Smith L&%

Corre!t "ns#er: 0

Rationa$e 1: The 'ord appears’ ma+es the entry an interpretation rather than an obser!ation"

Rationa$e 2: This entry describes 'hat the nurse obser!ed"

Rationa$e : This entry interprets the client’s actions or 'ords" A more accurate entry 'ould be: (date) ,7,,Client tal+ing on phone 'ith loud !oice" Stated ;>o' could you spend the mortgage money on a car<= Client

stated that she 'as tal+ing to her husband"6666S" Smith L&%"

Rationa$e 4: This entry is not appropriate as it is $i!e hours a$ter the medication 'as re$used and does not

include ;late entry"=

Rationa$e : This entry describes 'hat the nurse obser!ed"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:





Question 1

Type: MCSA

4hen accessing a client’s record the nursing student is care$ul to:

1. #se the instructor’s pass'ord"

2. Turn the monitor around 'hen 'al+ing a'ay $rom the computer"

. Lea!e notes and in$ormation in the $acility’s receptacle $or papers containing &>. 'hen $inished $or the day"

4. Allo' only the client’s $amily to see the notes"

Corre!t "ns#er: 3

Rationa$e 1: &ass'ords $or electronic medical records should not be shared"

Rationa$e 2: The student should sign out o$ the computer 'hen lea!ing the terminal"

Rationa$e : All material 'ith &>. (protected health in$ormation) should be le$t at the $acility and care plansshould only include initials to protect client con$identiality"

Rationa$e 4: The nurse should not allo' access to a client’s record by signi$icant others or any person other than

the healthcare pro!iders 'ho are directly in!ol!ed in the care o$ the client"

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: .mplementation(earning ut!ome:

Question 23

Type: MCMA

4hen correcting an incorrect entry or posting a late entry in an electronic medical record the nurse:


1. .ndicates the reason $or the correction"

2. .denti$ies the entry as a late entry"

. Enters the date the entry should ha!e been made"

4. Signs the entry"

. 2ocuments the late entries as soon as possible"





Corre!t "ns#er: -0

Rationa$e 1: The corrected entry should be labeled ;'rong patient= or other appropriate terminology"

Rationa$e 2: Late entries need to be labeled as such"

Rationa$e : Late entries need to be dated 'ith the date the entry is being made"

Rationa$e 4: The entry needs to be signed per agency protocol"

Rationa$e : Late entries need to be entered as soon as possible1 the longer the time lapse the less reliable the

entry becomes"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 21

Type: MCMA

#nderstanding the nursing process is essential to 'hich o$ the $ollo'ing types o$ documentation methods<


1. &.E charting

2. A&.E charting

. C?E 2AE documentation system

4. S?A& charting

. C*E

Corre!t "ns#er: -3

Rationa$e 1: &.E charting (problem inter!ention e!aluation) is based on the nursing process"

Rationa$e 2: A&.E charting (assessment problem inter!ention e!aluation) is based on the nursing process"

Rationa$e : C?E 2AE documentation system $ocuses on the nursing process1 it consists o$ a database plans o

care $lo' sheets progress notes and discharge summary" 2AE stands $or data action e!aluation"

Rationa$e 4: S?A& charting (sub@ecti!e data ob@ecti!e data assessment planning) is o$ten oriented around a

problem list"





Rationa$e : C*E (charting by e5ception) is a documentation system in 'hich only signi$icant $indings ore5ceptions to norms are recorded1 C*E includes uniue $lo' sheets documenting by re$erence to an agency’s

printed standards o$ nursing practice and documentation $orms at the bedside $or immediate recording"

%$o&a$ Rationa$e:




(earning ut!ome:

Question 22

Type: MCSA

The nurse 'ho 'or+s in a $acility that is changing $rom a source6oriented system o$ documentation to the BACT

system o$ documentation 'ill disco!er that the main di$$erence bet'een the t'o is:

1. The BACT system duplicates in$ormation"

2. The source6oriented system duplicates in$ormation"

. The BACT system documents progress in 2AE $ormat"

4. The BACT system is similar to C*E and is designed to eliminate redundant and irrele!ant data"

Corre!t "ns#er: /

Rationa$e 1: The BACT system consists o$ $lo' sheets that are indi!idualied an assessment sheet that is

standardied concise integrated progress notes and $lo' sheets and timely entries and is computer6ready" .t is

e$$icient and time6sa!ing"

Rationa$e 2: The source6oriented system tends to ha!e duplication o$ in$ormation as e!ery caregi!er ma+esentries in di$$erent parts o$ the record"

Rationa$e : The BACT system does not use the data action e!aluation $ormat o$ progress notes"

Rationa$e 4: The BACT system is named $or its elements and is designed to eliminate redundant and irrele!ant

data and inconsistencies in recording"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2





Type: MCMA

The L&%DL% is gi!ing change6o$6shi$t report to the oncoming nurse" eport on the client 'ho has @ust beenadmitted $rom the Emergency 2epartment $or an asthma attac+ should include:


1. %ame age and room number"

2. A list o$ the client’s problems"

. isitors 'ho ha!e seen the client including clergy"

4. >ead6to6toe re!ie'

. A medication list"

Corre!t "ns#er: -/


and in$ormation about the client’s support people"

Rationa$e 2: A current problem list including priorities and changes in condition during the shi$t should be

included"

Rationa$e : Comings and goings o$ !isitors is not included unless there is a problem or concern"

Rationa$e 4: eport on ne'ly admitted clients should include diagnosis age general condition plan o$ therapyand in$ormation about the client’s support people"

Rationa$e : A current medication list $or a ne' admission 'ill be o$ interest to ma+e sure continuity is

maintained"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 24

Type: MCSA

4hen e5plaining the purpose and characteristics o$ reporting to the ne' graduate the nurse summaries thecommon $eatures as:

1. .ndi!idualied"

2. Concise"





. 4ritten"

4. S*A $ormat"

Corre!t "ns#er:

Rationa$e 1: eporting may be gi!en to a group o$ nurses or to the nurse ta+ing o!er the nurse’s assigned clients"

Rationa$e 2: A report should be concise including pertinent in$ormation but should not include any e5traneousdetail"

Rationa$e : eporting may be 'ritten or oral"

Rationa$e 4: S*A $ormat (situation bac+ground assessment recommendation) is a $ormat that is use$ul inmany reporting situations but is not common to all reporting $ormats"

%$o&a$ Rationa$e:


C$ient Need: Sa$e E$$ecti!e Care En!ironmentC$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCSA

4hen con$irming telephone orders or other communication the L&%DL% documents:

1. *y 'hom the telephone order 'as recei!ed"

2. *y 'hom the !erbal order 'as recei!ed"

. Agency protocol"

4. -,,F read bac+"

Corre!t "ns#er: /

Rationa$e 1: %ot all telephone communication in!ol!es orders1 it can in!ol!e laboratory in$ormation"

Rationa$e 2: %ot all telephone communication in!ol!es orders1 it can in!ol!e laboratory in$ormation"

Rationa$e : Agency protocol should concur 'ith regulatory agency policy"

Rationa$e 4: The Goint Commission reuires that any in$ormation gi!en o!er the phone be repeated to the callerand documented as ;-,,F read bac+"=

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 2/

Type: MCMAThe student nurse is attending a nursing care con$erence" Characteristics o$ the nursing care con$erence include:


1. 2iscussing possible solutions to a client problem"

2. 4or+ing together as a group to create a plan o$ care"

. A climate o$ respect"

4. 2iscussion o$ nursing unit issues"

. Listening to others’ idea"

Corre!t "ns#er: -3

Rationa$e 1: The goal o$ the nursing care con$erence is to discuss possible solutions to certain client problems"

Rationa$e 2: %urses 'or+ together as a group to create a plan o$ care that is consistent"

Rationa$e : %urses 'or+ and communicate 'ith a climate o$ respect"

Rationa$e 4: 2iscussion o$ other issues on the nursing unit is not appropriate at this time"

Rationa$e : The nurses at a care con$erence listen to each other’s ideas 'ith an open mind to $ind a solution $or

the client problem"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 20

Type: MCMA

The L&%DL% 'ill o$ten be responsible $or completing the discharge note or re$erral summary" The in$ormation

to be documented includes:






1. esol!ed health problems"

2. Continuing health problems"

. Treatments that ha!e been completed"

4. Sel$6care abilities"

. Current medications"

Corre!t "ns#er: -/0

Rationa$e 1: esol!ed health problems need to be included as part o$ the database"

Rationa$e 2: Continuing health problems and care needs must be included $or appropriate $ollo'6up care"

Rationa$e : Treatments that are not to be continued are unnecessary to report"

Rationa$e 4: Sel$6care and $unctional abilities including !ision and hearing should be reported to the recei!ing

care $acility"

Rationa$e : Current medications need to be included in the report so that important therapies are not interrupted

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: %ursing &rocess: .mplementation(earning ut!ome:

Question 2

Type: MCSA

The nurse maintains accurate documentation in order to support 'hich o$ the $ollo'ing purposes o$ client

records<

1. A 'ritten or computer6based communication to others

2. A $ormal legal document that pro!ides e!idence o$ client care

. An in$ormal collection o$ in$ormation $or others to share

4. A $ormal computer6based record o$ the client

Corre!t "ns#er:





Rationa$e 1: The client record is a $ormal legal document o$ client care" A 'ritten or computer6basedcommunication to others is a $orm o$ report" The clientHs legal chart is not in$ormal and is not al'ays computer6

based" Many agencies still rely on the 'ritten chart"

Rationa$e 2: The client record is a $ormal legal document o$ client care" A 'ritten or computer6based

communication to others is a $orm o$ report" The clientHs legal chart is not in$ormal and is not al'ays computer6 based" Many agencies still rely on the 'ritten chart"

Rationa$e : The client record is a $ormal legal document o$ client care" A 'ritten or computer6basedcommunication to others is a $orm o$ report" The clientHs legal chart is not in$ormal and is not al'ays computer6


Rationa$e 4: The client record is a $ormal legal document o$ client care" A 'ritten or computer6based

communication to others is a $orm o$ report" The clientHs legal chart is not in$ormal and is not al'ays computer6


%$o&a$ Rationa$e:




(earning ut!ome:

Question 2

Type: MCMA

The nurse recognies that 'hich o$ the $ollo'ing is accurate regarding the clientHs medical record< Select all that

apply"


1. The insurance agencies ha!e a legal right to re!ie' the clientHs chart"

2. A client in!ol!ed in a la'suit may reuest that the chart be released to use as e!idence"

. Students may not use the charts $or research or educational purposes"

4. The client must sign an authoriation be$ore the chart can be released to another pro$essional"

. 4ritten report sheets bet'een shi$ts are not considered con$idential"

Corre!t "ns#er: /

Rationa$e 1: The client may reuest that the chart be used as e!idence during a la'suit and must sign

authoriation $or any in$ormation that is released $rom the chart" .nsurance companies do not ha!e a right to

re!ie' charts unless the client pro!ides authoriation $or them to see the in$ormation contained 'ithin it" ?$course $ailure to pro!ide authoriation releases the insurance company $rom obligation to reimburse $or the





clientHs medical treatment" Students may use client charts $or research and educational purposes" Any $orms thatcontain the clientHs name and in$ormation are considered con$idential material"




clientHs medical treatment" Students may use client charts $or research and educational purposes" Any $orms that

contain the clientHs name and in$ormation are considered con$idential material"

Rationa$e : The client may reuest that the chart be used as e!idence during a la'suit and must signauthoriation $or any in$ormation that is released $rom the chart" .nsurance companies do not ha!e a right to

re!ie' charts unless the client pro!ides authoriation $or them to see the in$ormation contained 'ithin it" ?$

course $ailure to pro!ide authoriation releases the insurance company $rom obligation to reimburse $or theclientHs medical treatment" Students may use client charts $or research and educational purposes" Any $orms that





clientHs medical treatment" Students may use client charts $or research and educational purposes" Any $orms thatcontain the clientHs name and in$ormation are considered con$idential material"

Rationa$e : The client may reuest that the chart be used as e!idence during a la'suit and must sign



clientHs medical treatment" Students may use client charts $or research and educational purposes" Any $orms that


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCSA

The nurse is caring $or a client 'hose ind'elling catheter 'as remo!ed early this morning" 4hich o$ the

$ollo'ing is correct documentation o$ urinary output $or this client<

1. The client !oided a large amount o$ urine"

2. The client states he !oided normal amounts o$ urine"





. oids in urinal uantity su$$icient"

4. oided /0, mL clear yello' urine"

Corre!t "ns#er: /

Rationa$e 1: 2ocumentation should be precise enough $or others to read the in$ormation and understand e5actly

'hat is 'ritten" 4ords li+e large or sufficient are not speci$ic and can mean di$$erent things to di$$erent people" .

the nurse documents /0, mL o$ urine it is speci$ic and means the same thing to all 'ho read it"

Rationa$e 2: 2ocumentation should be precise enough $or others to read the in$ormation and understand e5actly'hat is 'ritten" 4ords li+e large or sufficient are not speci$ic and can mean di$$erent things to di$$erent people" .

the nurse documents /0, mL o$ urine it is speci$ic and means the same thing to all 'ho read it"

Rationa$e : 2ocumentation should be precise enough $or others to read the in$ormation and understand e5actly

'hat is 'ritten" 4ords li+e large or sufficient are not speci$ic and can mean di$$erent things to di$$erent people" .the nurse documents /0, mL o$ urine it is speci$ic and means the same thing to all 'ho read it"

Rationa$e 4: 2ocumentation should be precise enough $or others to read the in$ormation and understand e5actly

'hat is 'ritten" 4ords li+e large or sufficient are not speci$ic and can mean di$$erent things to di$$erent people" .the nurse documents /0, mL o$ urine it is speci$ic and means the same thing to all 'ho read it"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 1Type: MCSA

The nurse con!erts 3:-9 p"m" to 'hat time using military time<

1. -3-9

2. ,3-9

. -0-9

4. ,-9

Corre!t "ns#er: 3

Rationa$e 1: Military time is o$ten used to pre!ent errors in time interpretation" 3:-9 p"m" is -0-9 in military time






Rationa$e : Military time is o$ten used to pre!ent errors in time interpretation" 3:-9 p"m" is -0-9 in military time


%$o&a$ Rationa$e:




(earning ut!ome:

Question 2

Type: MCSA

The nurse accepts 'hich o$ the $ollo'ing as proper legal documentation o$ complete bedrest $or three days<

1. C* $or three days

2. C* I3d

. * $or three days

4. C* $or 3d

Corre!t "ns#er: -

Rationa$e 1: C* is complete bedrest and is an acceptable abbre!iation" Three days should be 'ritten out because I3d could be misinterpreted"

Rationa$e 2: C* is complete bedrest and is an acceptable abbre!iation" Three days should be 'ritten out

because I3d could be misinterpreted"

Rationa$e : C* is complete bedrest and is an acceptable abbre!iation" Three days should be 'ritten out


Rationa$e 4: C* is complete bedrest and is an acceptable abbre!iation" Three days should be 'ritten out


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question





Type: MCMA

4hich o$ the $ollo'ing does the nurse use as a legally acceptable abbre!iation< Select all that apply"


1. "d"

2. MS

. *M

4. T&

. Lab"

Corre!t "ns#er: 3/0

Rationa$e 1: *M (bo'el mo!ement) T& (!ital signs) and lab" (laboratory) are all acceptable abbre!iations that

may be used in a medical $acility" The Goint Commission has identi$ied "d" (e!ery day) and MS (could beinterpreted as morphine sul$ate magnesium sul$ate or multiple sclerosis) as unacceptable abbre!iations"

Rationa$e 2: *M (bo'el mo!ement) T& (!ital signs) and lab" (laboratory) are all acceptable abbre!iations thatmay be used in a medical $acility" The Goint Commission has identi$ied "d" (e!ery day) and MS (could be

interpreted as morphine sul$ate magnesium sul$ate or multiple sclerosis) as unacceptable abbre!iations"

Rationa$e : *M (bo'el mo!ement) T& (!ital signs) and lab" (laboratory) are all acceptable abbre!iations that

may be used in a medical $acility" The Goint Commission has identi$ied "d" (e!ery day) and MS (could beinterpreted as morphine sul$ate magnesium sul$ate or multiple sclerosis) as unacceptable abbre!iations"

Rationa$e 4: *M (bo'el mo!ement) T& (!ital signs) and lab" (laboratory) are all acceptable abbre!iations thatmay be used in a medical $acility" The Goint Commission has identi$ied "d" (e!ery day) and MS (could be


Rationa$e : *M (bo'el mo!ement) T& (!ital signs) and lab" (laboratory) are all acceptable abbre!iations thatmay be used in a medical $acility" The Goint Commission has identi$ied "d" (e!ery day) and MS (could be


%$o&a$ Rationa$e:




(earning ut!ome:

Question 4

Type: MCSA





The nurse o$$ers to bathe the client and the client declines" 4hat is the best 'ay $or the nurse to document this

situation<

1. The client is re$using all care today"

2. The client is being noncompliant today"

. Client stated J. do not 'ant a bath today"J

4. The client did not 'ant a bath today"

Corre!t "ns#er: 3

Rationa$e 1: 4hene!er possible it is best to record the clientHs actual statement" To say that the client is re$using

all care today is inaccurate as the client only re$used the bath" 4riting that the client is noncompliant is a @udgment" Charting that the client did not 'ant a bath is inaccurate because perhaps the client did 'ant a bath but

didnHt 'ant it at that time" .$ charting e5actly 'hat the client said there can be no misinterpretation"

Rationa$e 2: 4hene!er possible it is best to record the clientHs actual statement" To say that the client is re$using



Rationa$e : 4hene!er possible it is best to record the clientHs actual statement" To say that the client is re$using



Rationa$e 4: 4hene!er possible it is best to record the clientHs actual statement" To say that the client is re$usingall care today is inaccurate as the client only re$used the bath" 4riting that the client is noncompliant is a

@udgment" Charting that the client did not 'ant a bath is inaccurate because perhaps the client did 'ant a bath butdidnHt 'ant it at that time" .$ charting e5actly 'hat the client said there can be no misinterpretation"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCSA

The client as+s $or a copy o$ his medical record" The best response by the nurse is 'hich o$ the $ollo'ing<

1. J.Hm sorry but 'e are not allo'ed to gi!e you a copy o$ the chart"J





2. J. 'ill get that $or you right a'ay"J

. J. 'ill ha!e to get permission $rom the doctor"J

4. J. 'ill need a 'ritten reuest $rom you to send to Medical ecords"J

Corre!t "ns#er: /

Rationa$e 1: The client has a right to obtain a copy o$ the chart but the reuest must be 'ritten and there might be a charge $or the copy" Telling the client that pro!iding a copy o$ the chart is not allo'ed is not true" The studen

may not copy the chart $or the client it must be copied by the Medical ecords department and permission $romthe doctor is not reuired" >o'e!er it 'ould be a courtesy to noti$y the doctor that the client reuested a copy o$

the chart"

Rationa$e 2: The client has a right to obtain a copy o$ the chart but the reuest must be 'ritten and there might

be a charge $or the copy" Telling the client that pro!iding a copy o$ the chart is not allo'ed is not true" The studenmay not copy the chart $or the client it must be copied by the Medical ecords department and permission $rom

the doctor is not reuired" >o'e!er it 'ould be a courtesy to noti$y the doctor that the client reuested a copy o$

the chart"

Rationa$e : The client has a right to obtain a copy o$ the chart but the reuest must be 'ritten and there might be a charge $or the copy" Telling the client that pro!iding a copy o$ the chart is not allo'ed is not true" The studen

may not copy the chart $or the client it must be copied by the Medical ecords department and permission $rom

the doctor is not reuired" >o'e!er it 'ould be a courtesy to noti$y the doctor that the client reuested a copy o$the chart"

Rationa$e 4: The client has a right to obtain a copy o$ the chart but the reuest must be 'ritten and there might

be a charge $or the copy" Telling the client that pro!iding a copy o$ the chart is not allo'ed is not true" The studen

may not copy the chart $or the client it must be copied by the Medical ecords department and permission $romthe doctor is not reuired" >o'e!er it 'ould be a courtesy to noti$y the doctor that the client reuested a copy o$

the chart"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCSA

A$ter documenting in the clientHs medical record the nurse realies it 'as the 'rong medical record and the

charting 'as $or another client" The nurseHs priority action is to do 'hich o$ the $ollo'ing<

1. #se a permanent mar+er to blac+ out the entry so that it cannot be read"





2. &ull out the page and discard it and reenter the in$ormation in the other clientHs record"

. 2ra' an I through the entry and 'rite Jerror 'rong chartJ and sign and date"

4. Co!er the entry 'ith brush6on correction $luid"

Corre!t "ns#er: 3

Rationa$e 1: 2ra' an I through the entry and 'rite Jerror 'rong chartJ and sign and date" &ulling out the page'ould also delete other entries that are legal parts o$ the record" #sing 'hite6out or a mar+er is not acceptable

because it obliterates the in$ormation"

Rationa$e 2: 2ra' an I through the entry and 'rite Jerror 'rong chartJ and sign and date" &ulling out the page'ould also delete other entries that are legal parts o$ the record" #sing 'hite6out or a mar+er is not acceptable

because it obliterates the in$ormation"

Rationa$e : 2ra' an I through the entry and 'rite Jerror 'rong chartJ and sign and date" &ulling out the page

'ould also delete other entries that are legal parts o$ the record" #sing 'hite6out or a mar+er is not acceptable because it obliterates the in$ormation"

Rationa$e 4: 2ra' an I through the entry and 'rite Jerror 'rong chartJ and sign and date" &ulling out the page

'ould also delete other entries that are legal parts o$ the record" #sing 'hite6out or a mar+er is not acceptable because it obliterates the in$ormation"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 0

Type: MCSA

4hen documenting in the clientHs computeried medical record 'hich o$ the $ollo'ing actions by the nurse migh

result in a breach o$ client con$identiality<

1. The nurse uses a pass'ord to access the clientHs record"

2. The nurse is chatting 'ith a co6'or+er 'hile the medication record is on the screen"

. The nurse turns the monitor so that it is not !isible $rom the hall'ay"

4. The nurse closes the clientHs record and signs o$$ the computer 'hen done"

Corre!t "ns#er:





Rationa$e 1: The co6'or+er is not caring $or the client and should not be !ie'ing anything about the client" Allother actions by the nurse are appropriate"

Rationa$e 2: The co6'or+er is not caring $or the client and should not be !ie'ing anything about the client" All

other actions by the nurse are appropriate"

Rationa$e : The co6'or+er is not caring $or the client and should not be !ie'ing anything about the client" Allother actions by the nurse are appropriate"

Rationa$e 4: The co6'or+er is not caring $or the client and should not be !ie'ing anything about the client" All

other actions by the nurse are appropriate"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCSA

4hile re!ie'ing a clientHs lab results the nurse also chec+s the results o$ a throat culture per$ormed yesterday on

the clientHs son" 4hich o$ the $ollo'ing is an accurate statement regarding this action<

1. The nurse breached con$identiality"

2. The nurse can legally chec+ this in$ormation i$ the child is under age -7"

. The nurse should as+ Medical ecords $or the sonHs results"

4. The nurse should as+ another nurse to loo+ up the in$ormation"

Corre!t "ns#er: -

Rationa$e 1: The nurse breached con$identiality as she 'as not caring $or the son and had no right to access thatrecord e!en i$ the child is under -7" The doctorHs nurse and the nurse caring $or the son cannot gi!e the

in$ormation to the nurse" Medical ecords cannot gi!e the in$ormation to the nurse"

Rationa$e 2: The nurse breached con$identiality as she 'as not caring $or the son and had no right to access thatrecord e!en i$ the child is under -7" The doctorHs nurse and the nurse caring $or the son cannot gi!e thein$ormation to the nurse" Medical ecords cannot gi!e the in$ormation to the nurse"

Rationa$e : The nurse breached con$identiality as she 'as not caring $or the son and had no right to access that

record e!en i$ the child is under -7" The doctorHs nurse and the nurse caring $or the son cannot gi!e the






Rationa$e 4: The nurse breached con$identiality as she 'as not caring $or the son and had no right to access thatrecord e!en i$ the child is under -7" The doctorHs nurse and the nurse caring $or the son cannot gi!e the


%$o&a$ Rationa$e:




(earning ut!ome:

Question

Type: MCSA

The ne'ly hired nurse is being oriented to the charting system used at the employing $acility" The preceptor tells

the nurse to $ind the nursing section o$ the clientHs record and document !ital signs and AM care" The nurse

recognies the $orm o$ documentation used at this $acility is 'hich o$ the $ollo'ing<

1. &roblem6oriented charting

2. S?A& charting

. Source6oriented charting

4. Bact6oriented charting

Corre!t "ns#er: 3

Rationa$e 1: .n source charting each discipline has its o'n area in the client record $or charting" S?A& is amethod o$ charting narrati!e inter!entions" &roblem6oriented records are charted by each discipline according tothe client problems" BACT charting uses a system o$ $lo' sheets that are indi!idualied $or the client"

Rationa$e 2: .n source charting each discipline has its o'n area in the client record $or charting" S?A& is a

method o$ charting narrati!e inter!entions" &roblem6oriented records are charted by each discipline according to

the client problems" BACT charting uses a system o$ $lo' sheets that are indi!idualied $or the client"

Rationa$e : .n source charting each discipline has its o'n area in the client record $or charting" S?A& is a

method o$ charting narrati!e inter!entions" &roblem6oriented records are charted by each discipline according to


Rationa$e 4: .n source charting each discipline has its o'n area in the client record $or charting" S?A& is amethod o$ charting narrati!e inter!entions" &roblem6oriented records are charted by each discipline according to


%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 43

Type: MCSA

The nurse is documenting 'ith a system that reuires an action and a response category" 4hat type o$ chartingsystem is the nurse using<

1. C*E

2. B?C#S

. S?A&

4. C?E

Corre!t "ns#er:

Rationa$e 1: The B?C#S method reuires action and responses" C*E is charting by e5ception" S?A& is a metho

o$ recording data using sub@ecti!e ob@ecti!e assessment and planning data 'hile C?E is charting $ocusing on

the nursing process"


o$ recording data using sub@ecti!e ob@ecti!e assessment and planning data 'hile C?E is charting $ocusing on


Rationa$e : The B?C#S method reuires action and responses" C*E is charting by e5ception"S?A& is a methodo$ recording data using sub@ecti!e ob@ecti!e assessment and planning data 'hile C?E is charting $ocusing on



o$ recording data using sub@ecti!e ob@ecti!e assessment and planning data 'hile C?E is charting $ocusing onthe nursing process"

%$o&a$ Rationa$e:




(earning ut!ome:

Question 41

Type: MCSA





The nurse recei!es a telephone order $rom the pro!ider" 4hich o$ the $ollo'ing actions by the nurse is

appropriate<

1. 4rite the main points o$ the order on a piece o$ paper to be transcribed later"

2. Consult 'ith another nurse be$ore documenting i$ the order is con$using"

. 4rite the medication order as 0", milligrams on the physicianHs order sheet"

4. >a!e the chart a!ailable in case the physician has uestions"

Corre!t "ns#er: /

Rationa$e 1: 4hen ta+ing a !erbal order the nurse 'rite the order as the physician gi!es it to her on the chart an

then repeats the order bac+ to the physician $or !eri$ication" The nurse should ha!e the chart a!ailable to ans'erthe physicianHs uestions as 'ell" 4hen 'riting medication orders a 'hole number is ne!er $ollo'ed by a

decimal point and ero because the decimal point could be missed and the client 'ould recei!e -, times the

ordered dosage" .$ the order is con$using the nurse should clari$y the order be$ore hanging up 'ith the pro!ider"4riting the order on a piece o$ paper instead o$ directly into the medical record ris+s losing the paper or

improperly transcribing the order"




ordered dosage" .$ the order is con$using the nurse should clari$y the order be$ore hanging up 'ith the pro!ider"4riting the order on a piece o$ paper instead o$ directly into the medical record ris+s losing the paper or

improperly transcribing the order"

Rationa$e : 4hen ta+ing a !erbal order the nurse 'rite the order as the physician gi!es it to her on the chart an



ordered dosage" .$ the order is con$using the nurse should clari$y the order be$ore hanging up 'ith the pro!ider"

4riting the order on a piece o$ paper instead o$ directly into the medical record ris+s losing the paper orimproperly transcribing the order"




ordered dosage" .$ the order is con$using the nurse should clari$y the order be$ore hanging up 'ith the pro!ider"4riting the order on a piece o$ paper instead o$ directly into the medical record ris+s losing the paper orimproperly transcribing the order"

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 42

Type: MCSA

4hen pro!iding report to the oncoming shi$t 'hich o$ the $ollo'ing data 'ould the nurse e5clude $rom thechange o$ shi$t report<

1. Mr" Timby recei!ed 0, mg o$ 2emerol .M at ,/3,"

2. Mrs" *u5tomHs !ital signs 'ere stable throughout the night"

. Mr" Lynn and Mr" Gones 'ere discharged tonight"

4. Mr" ShelbyHs 'i$e assists in gi!ing care to her husband"

Corre!t "ns#er: 3

Rationa$e 1: Since the clients are no longer in the $acility the ne5t shi$t does not need to +no' that Mr" Lynn and

Mr" Gones 'ere discharged" The oncoming nurse needs to +no' about medications !ital signs and concerns

e5pressed by the $amily o$ the client theyHll be caring $or throughout the shi$t"


Mr" Gones 'ere discharged" The oncoming nurse needs to +no' about medications !ital signs and concerns


Rationa$e : Since the clients are no longer in the $acility the ne5t shi$t does not need to +no' that Mr" Lynn andMr" Gones 'ere discharged" The oncoming nurse needs to +no' about medications !ital signs and concerns



Mr" Gones 'ere discharged" The oncoming nurse needs to +no' about medications !ital signs and concernse5pressed by the $amily o$ the client theyHll be caring $or throughout the shi$t"

%$o&a$ Rationa$e:




(earning ut!ome:

Question 4

Type: MCSA





The nurse is !isiting the client in the home to complete dressing changes and administer antibiotics" The nurse

$inishes care and is preparing to document $indings and care gi!en" 4hich o$ the $ollo'ing is accurate regarding

the charting $or the home health nurse<

1. The nurse retrie!es the chart $rom the physicianHs o$$ice be$ore the !isit"

2. The primary nurse +eeps the chart at all times"

. The chart is +ept 'ith the client so that the $amily can chart e!ents"

4. The nurse obtains the cart $rom the agency be$ore the !isit"

Corre!t "ns#er: 3

Rationa$e 1: .n home health care many di$$erent disciplines might be deli!ering care including the $amily" The

chart is +ept at the clientHs bedside in the home so that it is a!ailable to all caregi!ers pro!iding care including the

$amily"


chart is +ept at the clientHs bedside in the home so that it is a!ailable to all caregi!ers pro!iding care including the$amily"

Rationa$e : .n home health care many di$$erent disciplines might be deli!ering care including the $amily" The

chart is +ept at the clientHs bedside in the home so that it is a!ailable to all caregi!ers pro!iding care including the$amily"


chart is +ept at the clientHs bedside in the home so that it is a!ailable to all caregi!ers pro!iding care including the

$amily"

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Ramont2e Rev TIF Ch14

Documents

Transcript of Ramont2e Rev TIF Ch14