Chapter 9: Recording and Reporting
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1.A nurse enters a notation in a patients chart but then discovers that the notation was made in the wrong chart. The nurse correctly:
a.draws a single line through the notation so that it is still readable and writes mistaken entry, his sign and time. b.removes the page on which the error is written and rewrites the other correct notes. c.blacks out the note to protect the confidentiality of the patient about whom it was written and writes wrong patient, his signature, and the date and time. d.whites out the wrong entry and writes the note in the chart of the correct patient.
ANS: A When an error is made, no attempt to hide or obliterate the error should be made, because this may be questioned in a court of law. DIF: Cognitive Level: Application REF: d. 96, Box 7-4 OBJ: Theory #6 TOP: Charting Error Corrections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: basic care and comfort 2.A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, I dont want to have you draw any more blood for those useless tests. When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:
a.Refuses to have blood drawn. Doctor notified.
b.Refuses to have blood drawn; says tests are useless. Doctor notified.
c.Doctor notified of failure to draw ordered blood work.
d.Blood not drawn because tests are no longer desired by patient.
ANS: B When a patient refuses a treatment, the nurse should document the exact words of the patient regarding why the patient is refusing care. DIF: Cognitive Level: Application REF: d. 96, Box 7-4 OBJ: Clinical Practice #2 TOP: What to Document KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: basic care and comfort 3.A clinic nurse is documenting in a patient chart about the pain that brought the patient to seek medical attention. The best description is: a.Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch.
b.Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after c.Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse.
d.Peri-umbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief.
ANS: D When charting a sign or symptom, the nurse should include the quality (level 7 to 8), chronology (after lunch, last 3 hours), and aggravating or alleviating factors, as well as associated symptoms. DIF: Cognitive Level: Application REF: d. 95, Box 7-2 OBJ: Clinical Practice #2 TOP: The Charting Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: basic care and comfort 4.In a chart for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired , related to allergic reaction as evidenced by rash and hives, the nurse charts Subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm,
dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge. This type of charting is an example of: a.charting by exception. b.narrative style. c.a problem-oriented medical record (POMR). d.the case management system.
ANS: C The POMR focuses on a patient problem or nursing diagnosis and typically uses the SOAP (subjective, objective, assessment, plan) format as shown here. DIF: Cognitive Level: Application REF: d. 83 OBJ: Theory #4 TOP: Methods of Charting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5.In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) charting is that charting by exception:
a.is well suited to defending nursing actions in court.
b.contains important data certain to be noted in the narrative sections.
c.allows staff to learn the system quickly and easily.
d.highlights abnormal data and patient trends.
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1.A nurse enters a notation in a patients chart but then discovers that the notation was made in the wrong chart. The nurse correctly:
a.draws a single line through the notation so that it is still readable and writes mistaken entry, his sign and time. b.removes the page on which the error is written and rewrites the other correct notes. c.blacks out the note to protect the confidentiality of the patient about whom it was written and writes wrong patient, his signature, and the date and time. d.whites out the wrong entry and writes the note in the chart of the correct patient.
ANS: A When an error is made, no attempt to hide or obliterate the error should be made, because this may be questioned in a court of law. DIF: Cognitive Level: Application REF: d. 96, Box 7-4 OBJ: Theory #6 TOP: Charting Error Corrections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: basic care and comfort 2.A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, I dont want to have you draw any more blood for those useless tests. When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:
a.Refuses to have blood drawn. Doctor notified.
b.Refuses to have blood drawn; says tests are useless. Doctor notified.
c.Doctor notified of failure to draw ordered blood work.
d.Blood not drawn because tests are no longer desired by patient.
ANS: B When a patient refuses a treatment, the nurse should document the exact words of the patient regarding why the patient is refusing care. DIF: Cognitive Level: Application REF: d. 96, Box 7-4 OBJ: Clinical Practice #2 TOP: What to Document KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: basic care and comfort 3.A clinic nurse is documenting in a patient chart about the pain that brought the patient to seek medical attention. The best description is: a.Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch.
b.Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after c.Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse.
d.Peri-umbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief.
ANS: D When charting a sign or symptom, the nurse should include the quality (level 7 to 8), chronology (after lunch, last 3 hours), and aggravating or alleviating factors, as well as associated symptoms. DIF: Cognitive Level: Application REF: d. 95, Box 7-2 OBJ: Clinical Practice #2 TOP: The Charting Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: basic care and comfort 4.In a chart for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired , related to allergic reaction as evidenced by rash and hives, the nurse charts Subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm,
dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge. This type of charting is an example of: a.charting by exception. b.narrative style. c.a problem-oriented medical record (POMR). d.the case management system.
ANS: C The POMR focuses on a patient problem or nursing diagnosis and typically uses the SOAP (subjective, objective, assessment, plan) format as shown here. DIF: Cognitive Level: Application REF: d. 83 OBJ: Theory #4 TOP: Methods of Charting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5.In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) charting is that charting by exception:
a.is well suited to defending nursing actions in court.
b.contains important data certain to be noted in the narrative sections.
c.allows staff to learn the system quickly and easily.
d.highlights abnormal data and patient trends.
