Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 26: Documentation and Informatics
MULTIPLE CHOICE
1. The nurse is preparing the information that will be provided to the staff on the next shift.
Which of the following should the nurse include in the inter-shift report to nursing col-
leagues?
1. Audit of client care procedures
2. The client’s diagnostic-related group
3. All routine care procedures required by
the client
4. Instructions given to the client in a teach-
ing plan
ANS: 4
A change-of-shift report should include instructions given in a teaching plan and the cli-
ent’s response. This should not include detailed content unless staff members ask for cla-
rification. The nurse should relay to staff significant changes in the way therapies are giv-
en, but should not describe basic steps of a procedure. The client’s diagnosis-related
group is not essential background information to be shared in an inter-shift report. The
nurse should not review all routine care procedures or tasks.
DIF: A REF: 399 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
2. An incident report is to be completed because the client climbed over the side rails and
fell to the floor. The correct reporting of an incident involves which of the following?
1. The witnessing nurse completes the re-
port.
2. Details of the incident are subjectively de-
scribed.
3. An explanation of the possible cause for
the incident is entered.
4. A notation is included in the medical re-
cord that an incident report was prepared.
ANS: 1
The nurse who witnessed the incident is the one who completes the report. Details of the
incident should be objectively described. An explanation of the possible cause is not in-
cluded. The sequence of events is described objectively. A notation is not included in the
medical record that an incident report was written.
, DIF: A REF: 403 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
3. Which is the most appropriate notation for a use to use according to the guidelines that
should be followed when documenting client care?
1. 1230—Client’s vital signs taken.
2. 0700—Client drank adequate amount of
fluids.
3. 0900—Demerol given for lower abdomin-
al pain.
4. 0830—Increased IV fluid rate to 100
mL/hr according to protocol.
ANS: 4
Information within a recorded entry needs to be complete, containing appropriate and es-
sential information. This notation (0830) provides the time and action taken by the nurse
including the reason for doing so. This entry (1230) does not indicate what the vital signs
were. This entry (0700) does not provide the specific amount the client drank. Stating
“adequate” is subjective, not objective. This notation (0900) does not have the client de-
scribe his or her pain or rate it according to a pain scale for comparison later. It also does
not indicate whether the client’s pain was in the lower left or lower right quadrant, or
both.
DIF: A REF: 389 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
4. The nurse makes a late entry in a client’s record. Which of the following is the best ex-
ample of how to document this type of situation?
1. “2:45 PM—ASA gr X given for temperat-
ure of 38.1° C.”
2. “8:30 AM—Client received Percodan (1
tablet) PO an hour before going to radi-
ology.”
3. “12:15 PM—I gave the client morphine 10
mg IM at 11:10 AM but did not document
it then.”
4. “8:30 PM—Abdominal dressing change at
7:30 PM. No s/s of infection, and wound
edges approximating well.”
ANS: 1
This is the best example of a late entry. The time (2:45 PM) is indicated along with the ac-
tion and an objective observation. This notation (8:30 AM) is not complete. It does not in-
dicate why the Percodan was given. What was the client’s level of pain? Where was the
Test Bank
Chapter 26: Documentation and Informatics
MULTIPLE CHOICE
1. The nurse is preparing the information that will be provided to the staff on the next shift.
Which of the following should the nurse include in the inter-shift report to nursing col-
leagues?
1. Audit of client care procedures
2. The client’s diagnostic-related group
3. All routine care procedures required by
the client
4. Instructions given to the client in a teach-
ing plan
ANS: 4
A change-of-shift report should include instructions given in a teaching plan and the cli-
ent’s response. This should not include detailed content unless staff members ask for cla-
rification. The nurse should relay to staff significant changes in the way therapies are giv-
en, but should not describe basic steps of a procedure. The client’s diagnosis-related
group is not essential background information to be shared in an inter-shift report. The
nurse should not review all routine care procedures or tasks.
DIF: A REF: 399 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
2. An incident report is to be completed because the client climbed over the side rails and
fell to the floor. The correct reporting of an incident involves which of the following?
1. The witnessing nurse completes the re-
port.
2. Details of the incident are subjectively de-
scribed.
3. An explanation of the possible cause for
the incident is entered.
4. A notation is included in the medical re-
cord that an incident report was prepared.
ANS: 1
The nurse who witnessed the incident is the one who completes the report. Details of the
incident should be objectively described. An explanation of the possible cause is not in-
cluded. The sequence of events is described objectively. A notation is not included in the
medical record that an incident report was written.
, DIF: A REF: 403 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
3. Which is the most appropriate notation for a use to use according to the guidelines that
should be followed when documenting client care?
1. 1230—Client’s vital signs taken.
2. 0700—Client drank adequate amount of
fluids.
3. 0900—Demerol given for lower abdomin-
al pain.
4. 0830—Increased IV fluid rate to 100
mL/hr according to protocol.
ANS: 4
Information within a recorded entry needs to be complete, containing appropriate and es-
sential information. This notation (0830) provides the time and action taken by the nurse
including the reason for doing so. This entry (1230) does not indicate what the vital signs
were. This entry (0700) does not provide the specific amount the client drank. Stating
“adequate” is subjective, not objective. This notation (0900) does not have the client de-
scribe his or her pain or rate it according to a pain scale for comparison later. It also does
not indicate whether the client’s pain was in the lower left or lower right quadrant, or
both.
DIF: A REF: 389 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
4. The nurse makes a late entry in a client’s record. Which of the following is the best ex-
ample of how to document this type of situation?
1. “2:45 PM—ASA gr X given for temperat-
ure of 38.1° C.”
2. “8:30 AM—Client received Percodan (1
tablet) PO an hour before going to radi-
ology.”
3. “12:15 PM—I gave the client morphine 10
mg IM at 11:10 AM but did not document
it then.”
4. “8:30 PM—Abdominal dressing change at
7:30 PM. No s/s of infection, and wound
edges approximating well.”
ANS: 1
This is the best example of a late entry. The time (2:45 PM) is indicated along with the ac-
tion and an objective observation. This notation (8:30 AM) is not complete. It does not in-
dicate why the Percodan was given. What was the client’s level of pain? Where was the
