Fundamentals of Nursing 10th Edition Lippincott - Test Bank Chapter 20
Study online at https://quizlet.com/_gr1xcr
1. A CLIENT'S DIAGNOSIS OF PNEU- A) Avelox (Moxifloxacin) 400 MG daily
MONIA REQUIRES TREATMENT WITH
ANTIBIOTICS. THE CORRESPONDING AMONG THE JCAHO'S LIST OF "DO NOT USE ABBRE-
ORDER IN THE CLIENT'S CHART VIATIONS" ARE Q.D., QD, AND OD WHEN DENOTING
SHOULD BE WRITTEN AS: A ONCE-PER-DAY DRUG ADMINISTRATION. BECAUSE
OF THE POTENTIAL FOR MISINTERPRETATION AND
A) AVELOX (MOXIFLOXACIN) 400 MG CONSEQUENT DRUG ERRORS, THE JCAHO RECOM-
DAILY MENDS WRITING "DAILY" IN THE ORDER
B) AVELOX (MOXIFLOXACIN) 400 MG
Q.D.
C) AVELOX (MOXIFLOXACIN) 400 MG
QD
D) AVELOX (MOXIFLOXACIN) 400 MG
OD
2. THE NURSES WHO PROVIDE CARE IN A) Vulnerability to legal liability since a nurse's safe,
A LARGE, LONG-TERM CARE FACILI- routine care is not recorded
TY UTILIZE CHARTING BY EXCEPTION
(CBE) AS THE PREFERRED METHOD A SIGNIFICANT DRAWBACK TO CHARTING BY EXCEP-
OF DOCUMENTATION. THIS DOC- TION IS ITS LIMITED USEFULNESS WHEN TRYING TO
UMENTATION METHOD MAY HAVE PROVE HIGH-QUALITY SAFE CARE IN RESPONSE TO A
WHICH OF THE FOLLOWING DRAW- NEGLIGENCE CLAIM MADE AGAINST NURSING. CBE
BACKS? IS GENERALLY LESS TIME-CONSUMING THAN ALTER-
NATE METHODS OF DOCUMENTATION, AND BOTH
A) VULNERABILITY TO LEGAL LIABIL- STANDARDIZATION OF CHARTING AND IDENTIFICA-
ITY SINCE NURSE'S SAFE, ROUTINE TION OF CLIENT-SPECIFIC PROBLEMS ARE POSSIBLE
CARE IS NOT RECORDED WITHIN THIS DOCUMENTATION FRAMEWORK.
B) INCREASED WORKLOAD FOR
NURSES IN ORDER TO COMPLETE
NECESSARY DOCUMENTATION
C) FAILURE TO IDENTIFY AND
RECORD CLIENT PROBLEMS AND AS-
, Fundamentals of Nursing 10th Edition Lippincott - Test Bank Chapter 20
Study online at https://quizlet.com/_gr1xcr
SOCIATED INTERVENTIONS
D) SIGNIFICANT DIFFERENCES IN
THE CHARTING BETWEEN NURSES
DUE TO LACK OF STANDARDIZATION
3. THE NURSE MANAGERS OF A HOME A) Narrative notes
HEALTH CARE OFFICE WISH TO MAX-
IMIZE NURSES' FREEDOM TO CHAR- ONE OF THE ADVANTAGES OF A NARRATIVE NOTES
ACTERIZE AND RECORD CLIENT CON- MODEL OF DOCUMENTATION IS THAT IT ALLOWS
DITIONS AND SITUATIONS IN THE NURSES TO DESCRIBE CLINICAL ENCOUNTERS IN
NURSES' OWN TERMS. WHICH OF THEIR OWN TERMS, AS THEY UNDERSTAND THEM.
THE FOLLOWING DOCUMENTATION OTHER DOCUMENTATION FORMATS, SUCH AS SOAP
FORMATS IS MOST LIKELY TO PRO- NOTES, FOCUS CHARTING, AND CHARTING BY EXCEP-
MOTE THIS GOAL? TION, ARE MORE RIGIDLY DELINEATED AND ALLOW
NURSES LESS LATITUDE IN THEIR DOCUMENTATION.
A) NARRATIVE NOTES
B) SOAP NOTES
C) FOCUS CHARTING
D) CHARTING BY EXCEPTION
4. A HOSPITAL UTILIZES THE SOAP A) "Client complaining of abdominal pain rated at
METHOD OF CHARTING. WITH- 8/10."
IN THIS MODEL, WHICH OF THE
NURSE'S FOLLOWING STATEMENTS THE SOAP METHOD OF CHARTING (SUBJECTIVE DATA,
WOULD APPEAR AT THE BEGINNING OBJECTIVE DATA, ASSESSMENT, PLAN) BEGINS WITH
OF A CHARTING ENTRY? THE INFORMATION PROVIDED BY THE CLIENT, SUCH
AS A COMPLAINT OF PAIN. THE NURSE'S OBJECTIVE
A) "CLIENT COMPLAINING OF AB- OBSERVATIONS AND ASSESSMENTS FOLLOW, WITH
DOMINAL PAIN RATED AT 8/10." INTERVENTIONS, ACTIONS, AND PLANS LATER IN THE
B) "CLIENT IS GUARDING HER CHARTING ENTRY.
ABDOMEN AND OCCASIONALLY
MOANING."
, Fundamentals of Nursing 10th Edition Lippincott - Test Bank Chapter 20
Study online at https://quizlet.com/_gr1xcr
C) "CLIENT HAS A HISTORY OF RE-
CENT ABDOMINAL PAIN."
D) "2 MG DILAUDID PO ADMINIS-
TERED WITH GOOD EFFECT."
5. WHAT IS THE NURSE'S BEST DEFENSE C) Client's record
IF A CLIENT ALLEGES NURSING NEG-
LIGENCE? THE CLIENT RECORD IS THE ONLY PERMANENT LEGAL
A) TESTIMONY OF OTHER NURSES DOCUMENT THAT DETAILS THE NURSE'S INTERAC-
B) TESTIMONY OF EXPERT WITNESS- TIONS WITH THE CLIENT. IT IS THE BEST DEFENSE IF
ES A CLIENT OR CLIENT SURROGATE ALLEGES NURSING
C) CLIENT'S RECORD NEGLIGENCE.
D) CLIENT'S FAMILY
6. A NURSE IS DOCUMENTING THE IN- D) "Client states pain is a 9 on a scale of 1 to 10."
TENSITY OF A CLIENT'S PAIN. WHAT
WOULD BE THE MOST ACCURATE EN- INFORMATION SHOULD BE DOCUMENTED IN A
TRY? COMPLETE, ACCURATE, RELEVANT, AND FACTUAL
MANNER. AVOID INTERPRETATIONS OF BEHAVIOR,
A) "CLIENT COMPLAINING OF SE- GENERALIZATIONS, AND WORDS SUCH AS "GOOD."
VERE PAIN."
B) "CLIENT APPEARS TO BE IN A LOT
OF PAIN AND IS CRYING."
C) "CLIENT STATES HAS PAIN; WALK-
ING IN HALL WITH EASE."
D) "CLIENT STATES PAIN IS A 9 ON A
SCALE OF 1 TO 10."
7. WHICH OF THE FOLLOWING DATA C) "Following oxygen administration, vital signs re-
ENTRIES FOLLOWS THE RECOM- turned to baseline."
MENDED GUIDELINES FOR DOCU-
MENTING DATA? THE NURSE SHOULD RECORD CLIENT FINDINGS (OB-
SERVATIONS OF BEHAVIOR) RATHER THAN AN INTER-
Study online at https://quizlet.com/_gr1xcr
1. A CLIENT'S DIAGNOSIS OF PNEU- A) Avelox (Moxifloxacin) 400 MG daily
MONIA REQUIRES TREATMENT WITH
ANTIBIOTICS. THE CORRESPONDING AMONG THE JCAHO'S LIST OF "DO NOT USE ABBRE-
ORDER IN THE CLIENT'S CHART VIATIONS" ARE Q.D., QD, AND OD WHEN DENOTING
SHOULD BE WRITTEN AS: A ONCE-PER-DAY DRUG ADMINISTRATION. BECAUSE
OF THE POTENTIAL FOR MISINTERPRETATION AND
A) AVELOX (MOXIFLOXACIN) 400 MG CONSEQUENT DRUG ERRORS, THE JCAHO RECOM-
DAILY MENDS WRITING "DAILY" IN THE ORDER
B) AVELOX (MOXIFLOXACIN) 400 MG
Q.D.
C) AVELOX (MOXIFLOXACIN) 400 MG
QD
D) AVELOX (MOXIFLOXACIN) 400 MG
OD
2. THE NURSES WHO PROVIDE CARE IN A) Vulnerability to legal liability since a nurse's safe,
A LARGE, LONG-TERM CARE FACILI- routine care is not recorded
TY UTILIZE CHARTING BY EXCEPTION
(CBE) AS THE PREFERRED METHOD A SIGNIFICANT DRAWBACK TO CHARTING BY EXCEP-
OF DOCUMENTATION. THIS DOC- TION IS ITS LIMITED USEFULNESS WHEN TRYING TO
UMENTATION METHOD MAY HAVE PROVE HIGH-QUALITY SAFE CARE IN RESPONSE TO A
WHICH OF THE FOLLOWING DRAW- NEGLIGENCE CLAIM MADE AGAINST NURSING. CBE
BACKS? IS GENERALLY LESS TIME-CONSUMING THAN ALTER-
NATE METHODS OF DOCUMENTATION, AND BOTH
A) VULNERABILITY TO LEGAL LIABIL- STANDARDIZATION OF CHARTING AND IDENTIFICA-
ITY SINCE NURSE'S SAFE, ROUTINE TION OF CLIENT-SPECIFIC PROBLEMS ARE POSSIBLE
CARE IS NOT RECORDED WITHIN THIS DOCUMENTATION FRAMEWORK.
B) INCREASED WORKLOAD FOR
NURSES IN ORDER TO COMPLETE
NECESSARY DOCUMENTATION
C) FAILURE TO IDENTIFY AND
RECORD CLIENT PROBLEMS AND AS-
, Fundamentals of Nursing 10th Edition Lippincott - Test Bank Chapter 20
Study online at https://quizlet.com/_gr1xcr
SOCIATED INTERVENTIONS
D) SIGNIFICANT DIFFERENCES IN
THE CHARTING BETWEEN NURSES
DUE TO LACK OF STANDARDIZATION
3. THE NURSE MANAGERS OF A HOME A) Narrative notes
HEALTH CARE OFFICE WISH TO MAX-
IMIZE NURSES' FREEDOM TO CHAR- ONE OF THE ADVANTAGES OF A NARRATIVE NOTES
ACTERIZE AND RECORD CLIENT CON- MODEL OF DOCUMENTATION IS THAT IT ALLOWS
DITIONS AND SITUATIONS IN THE NURSES TO DESCRIBE CLINICAL ENCOUNTERS IN
NURSES' OWN TERMS. WHICH OF THEIR OWN TERMS, AS THEY UNDERSTAND THEM.
THE FOLLOWING DOCUMENTATION OTHER DOCUMENTATION FORMATS, SUCH AS SOAP
FORMATS IS MOST LIKELY TO PRO- NOTES, FOCUS CHARTING, AND CHARTING BY EXCEP-
MOTE THIS GOAL? TION, ARE MORE RIGIDLY DELINEATED AND ALLOW
NURSES LESS LATITUDE IN THEIR DOCUMENTATION.
A) NARRATIVE NOTES
B) SOAP NOTES
C) FOCUS CHARTING
D) CHARTING BY EXCEPTION
4. A HOSPITAL UTILIZES THE SOAP A) "Client complaining of abdominal pain rated at
METHOD OF CHARTING. WITH- 8/10."
IN THIS MODEL, WHICH OF THE
NURSE'S FOLLOWING STATEMENTS THE SOAP METHOD OF CHARTING (SUBJECTIVE DATA,
WOULD APPEAR AT THE BEGINNING OBJECTIVE DATA, ASSESSMENT, PLAN) BEGINS WITH
OF A CHARTING ENTRY? THE INFORMATION PROVIDED BY THE CLIENT, SUCH
AS A COMPLAINT OF PAIN. THE NURSE'S OBJECTIVE
A) "CLIENT COMPLAINING OF AB- OBSERVATIONS AND ASSESSMENTS FOLLOW, WITH
DOMINAL PAIN RATED AT 8/10." INTERVENTIONS, ACTIONS, AND PLANS LATER IN THE
B) "CLIENT IS GUARDING HER CHARTING ENTRY.
ABDOMEN AND OCCASIONALLY
MOANING."
, Fundamentals of Nursing 10th Edition Lippincott - Test Bank Chapter 20
Study online at https://quizlet.com/_gr1xcr
C) "CLIENT HAS A HISTORY OF RE-
CENT ABDOMINAL PAIN."
D) "2 MG DILAUDID PO ADMINIS-
TERED WITH GOOD EFFECT."
5. WHAT IS THE NURSE'S BEST DEFENSE C) Client's record
IF A CLIENT ALLEGES NURSING NEG-
LIGENCE? THE CLIENT RECORD IS THE ONLY PERMANENT LEGAL
A) TESTIMONY OF OTHER NURSES DOCUMENT THAT DETAILS THE NURSE'S INTERAC-
B) TESTIMONY OF EXPERT WITNESS- TIONS WITH THE CLIENT. IT IS THE BEST DEFENSE IF
ES A CLIENT OR CLIENT SURROGATE ALLEGES NURSING
C) CLIENT'S RECORD NEGLIGENCE.
D) CLIENT'S FAMILY
6. A NURSE IS DOCUMENTING THE IN- D) "Client states pain is a 9 on a scale of 1 to 10."
TENSITY OF A CLIENT'S PAIN. WHAT
WOULD BE THE MOST ACCURATE EN- INFORMATION SHOULD BE DOCUMENTED IN A
TRY? COMPLETE, ACCURATE, RELEVANT, AND FACTUAL
MANNER. AVOID INTERPRETATIONS OF BEHAVIOR,
A) "CLIENT COMPLAINING OF SE- GENERALIZATIONS, AND WORDS SUCH AS "GOOD."
VERE PAIN."
B) "CLIENT APPEARS TO BE IN A LOT
OF PAIN AND IS CRYING."
C) "CLIENT STATES HAS PAIN; WALK-
ING IN HALL WITH EASE."
D) "CLIENT STATES PAIN IS A 9 ON A
SCALE OF 1 TO 10."
7. WHICH OF THE FOLLOWING DATA C) "Following oxygen administration, vital signs re-
ENTRIES FOLLOWS THE RECOM- turned to baseline."
MENDED GUIDELINES FOR DOCU-
MENTING DATA? THE NURSE SHOULD RECORD CLIENT FINDINGS (OB-
SERVATIONS OF BEHAVIOR) RATHER THAN AN INTER-
