Preview Extract
Chapter 6
1. The nursing staff members have exhausted all possible interventions to avoid placing a patient in restraints. Which of the following orders for physical restraints is written correctly?
1. 2/3/09, 1815, apply soft wrist restraints for 24 hours to prevent the removal of IV line, Dr. X
2. 2/3/09, apply restraints for 24 hours due to failure of nonrestraint nursing interventions, Dr. X
3. 2/3/09, 1815, apply soft wrist restraints for 48 hours to prevent injury, Dr. X
4. 2/3/09, To prevent falls apply restraints as needed at night, Dr. X
Answer: 2/3/09, 1815, apply soft wrist restraints for 24 hours to prevent the removal of IV line, Dr. X
Rationale:
Restraint orders must contain the date and time of the order, reason for the restraint use, duration of restraint use, type of restraint, and the health care provider’s signature. The order must be reviewed and renewed every 24 hours.
2. A hospital would be in danger of losing Medicare and Medicaid funding for the violation of which of the following regulatory agent’s standards?
1. The Joint Commission and Health Insurance Portability and Accountability Act
2. The Joint Commission and Nurse Practice Act
3. The American Nurses Association and Health Insurance Portability and Accountability Act
4. The Nurse Practice Act and American Nurses Association
Answer: The Joint Commission and Health Insurance Portability and Accountability Act
Rationale:
The Joint Commission and Health Insurance Portability and Accountability Act allow for the loss of Medicare and Medicaid funding for not complying with standards for safe health and releasing client information without proper consent of the client. The American Nurses Association (ANA) has guidelines regarding documentation. State nurse practice acts (NPAs) have standards to ensure safe practice. The ANA and NPAs cannot fine or remove funding for violation of documentation and safe practice standards.
3. A hospital is being surveyed by the Joint Commission and will be experiencing the Joint Commission’s tracer methodology. The nursing staff should be prepared to allow the surveyor:
1. Access to one patient’s medical record to determine if the organization has complied with Joint Commission standards for patient care.
2. Access to patients to gain the clients’ consent to review their medical records.
3. Access to documentation indicating the organization is exploring ways to improve the quality of client care.
4. Access to monitoring results of the organization’s effort to improve the quality of client care.
Answer: Access to one patient’s medical record to determine if the organization has complied with Joint Commission standards for patient care.
Rationale:
The Joint Commission currently uses a tracer methodology during accreditation visits. The site surveyor will choose a patient who is hospitalized and use the patient’s clinical record as a “road map.” The surveyor reviews the care documented to determine if the organization has complied with standards and systems for providing care. The Joint Commission surveyor would not need consent to review a client’s record. The surveyor would adhere to the Health Insurance Portability and Accountability Act Privacy Rule, which indicates that the patient or those health team members involved with the patient’s care have a legal right to review the medical record. Access to documentation indicating the organization is exploring ways to improve the quality of client care is part of the surveyor’s visit but is not a part of the tracer method. Access to monitoring results of the organization’s effort to improve the quality of client care is part of the surveyor’s visit but is not a part of the tracer method.
4. A nurse is providing care for a client who is unhappy with the health care provider’s care. The client signs the Against Medical Advice (AMA) form and leaves the hospital against medical advice. The nurse should include which of the following in the documentation of this event in the client’s medical record or on the AMA form?
Select all that apply.
1. Documentation that the client has been informed that he or she is leaving against medical advice.
2. Documentation of explanation of the risks of leaving against medical advice.
3. Documentation of any discharge instructions given to the client.
4. Documentation indicating an incident report has been completed.
5. Documentation that the client has been informed that he or she cannot come back to the hospital.
Answer: 1. Documentation that the client has been informed that he or she is leaving against medical advice.
2. Documentation of explanation of the risks of leaving against medical advice.
3. Documentation of any discharge instructions given to the client.
Rationale:
Documentation that the client has been informed that he or she is leaving against medical advice. It should be clearly documented that the patient has been advised that he or she is leaving against medical advice in the client’s record as well as on the AMA form. Documentation of explanation of the risks of leaving against medical advice. It should be clearly documented that the client understands the risks of leaving on the AMA form. Documentation of any discharge instructions given to the client. The AMA form includes the name of person accompanying the client and any discharge instructions given. Documentation that the client has been informed that he or she cannot come back to the hospital. It should be clearly documented that the client been advised and understands that he or she can come back. Documentation indicating an incident report has been completed. Facility policy may require that an incident report be completed, but it must not be referenced in the chart. The client’s record is a legal document, so the nurse should never document that he or she filed an incident report.
5. A nurse documents the following statement in a client’s medical record: “2/25/09, 2235, At 2015 client awoke suddenly and complained of shortness of air. Pulse oximetry reading was 82% on room air and audible wheezes could be heard.” This documentation meets which of the following documentation guidelines?
Select all that apply.
1. Documentation is complete, concise, and accurate
2. Documentation is objective
3. Documentation includes the date and time of entry
4. Documentation is timely
5. Documentation is labeled late entry
Answer: 1. Documentation is complete, concise, and accurate
2. Documentation is objective
3. Documentation includes the date and time of entry
Rationale:
Documentation is complete, concise, and accurate. Document only facts: what you can see, hear, and do. Describe what you see and do not be vague. Documentation is objective. Describe factual occurrences that you can see, hear, smell, or touch. Be objective and avoid vague statements that are subjective. Documentation includes the date and time of entry. Documenting the sequence of events and changes in patient condition is essential and should be documented as soon as possible after an observation is made or care is provided. Documentation is timely. Document as soon as possible after an observation is made or care is provided. Documentation that is done concurrently with the care provided is more likely to be accurate and complete. Deviation from the standard of care or poor documentation of care can lead to allegations of negligence. Documentation is labeled late entry. The entry was made in the client’s medical record at least 2 hours after the patient complaint and should be labeled late entry. If you have forgotten to document something, or need to add important information, add the entry on the first available line and record the current date and time; label it late entry.
6. A nurse documents the following in a client’s medical record: “2/1/09, 1500, Client appears weak and faint. Client’s skin is moist and cool, vomited bright red blood with clots. Health care provider notified and order received to give 2 u of packed red blood cells if stat Hgb is < 8.0.” This is an example of documentation that reflects:
1. A change in a client’s condition.
2. Appropriate use of abbreviations.
3. Objective data only.
4. Documentation of a procedure in advance.
Answer: A change in a client’s condition.
Rationale:
In general, employers, and state, federal, and professional standards require documentation to include initial and ongoing assessments, any change in the patient’s condition, therapies given and patient response, patient teaching, and relevant statements by the client. The Joint Commission has designated the inappropriateness of “u” as an abbreviation. “U” should be written out as “unit(s)”. If unsure, the abbreviation is correct, spell out the word; “<” can be misinterpreted, so it should be spelled out as “less than.” Be objective and avoid vague statements that are subjective. Describe factual occurrences that can be seen, heard, smelled, or touched. The use of the word “appears” is subjective and could be manipulated later should the treatment or judgment be challenged. The client record is a legal document, so the nurse should never document procedures or medication administration in advance. The nurse has documented the order received; the documentation does not say the packed red blood cells were infused at a later time.
7. The charting by exception documentation system saves time by:
1. Eliminating lengthy or repetitive documentation.
2. Eliminating repetition and promoting consistent language.
3. Allowing the reader to easily locate information about a specific problem.
4. Allowing flexibility and description in the documentation.
Answer: Eliminating lengthy or repetitive documentation.
Rationale:
Charting by exception is used to eliminate lengthy or repetitive documentation. The FACT (flow sheet, assessment, concise, timely) system eliminates repetition and promotes consistent language. The focus system allows the reader to easily locate information about a specific problem. Flexible and descriptive documentation is an advantage of the narrative system.
8. A documentation system that allows for minimizing the risk of medication errors is the:
1. Electronic medical record.
2. Problem-oriented medical record.
3. Problem, intervention, evaluation system.
4. Focus system.
Answer: Electronic medical record.
Rationale:
The electronic medical record decreases errors and allows for the reconciliation of the client’s medications on admission, daily, and on discharge. The five components of the problem-oriented medical record are baseline data, a problem list, a plan of care for each problem, multidisciplinary progress notes, and a discharge summary. The problem, intervention, and evaluation system consists of a list of the client’s problems, followed by the interventions taken to alleviate the problem, and lastly the evaluation of the client’s response to the intervention. The focus system documentation system focuses on a data-action-response format. Medication error prevention is not discussed with the focus system.
9. The omission of the planning stage of the nursing process is a disadvantage of which documentation system?
1. Problem, intervention, evaluation system
2. Problem-oriented medical record
3. Focus system
4. Electronic medical record
Answer: Problem, intervention, evaluation system
Rationale:
The problem, intervention, evaluation system does not document the planning step in the nursing process, which addresses expected outcomes. In the problem-oriented medical record, after a nurse lists the client’s problems, an initial plan of care is developed that includes expected outcomes, plans for further data collection, patient care, and teaching plans. The focus system includes a detailed patient assessment leading to the development of patient-centered problems that are expressed as nursing diagnoses. Subsequent documentation focuses on data-action-response. The electronic medical record utilizes nursing information systems that contain most of the components of the nursing process and therefore adheres to the Joint Commission documentation standard that care is planned and provided in an interdisciplinary, collaborative manner by qualified individuals.
10. When completing a Preparation for Practice exercise, the learner would utilize which of the following forms for applying the nursing process to a specific patient situation?
1. Concept map
2. Kardex
3. Summary of hospitalization
4. Laboratory results
Answer: Concept map
Rationale:
The concept map is the actual nursing care plan utilizing the nursing process and includes medical and nursing interventions. The Kardex is not identified as a form to be completed during the Preparation for Practice exercise. The summary of hospitalization form includes pertinent information including the basic care needed for the client. Laboratory analysis addresses the cause of abnormalities and the significance of the findings.
11. The Preparation for Practice exercises at the end of the chapters that cover a disorder will assist the learner in:
Select all that apply.
1. Developing a problem-solving approach to nursing care.
2. Gaining experience in critical thinking skills.
3. Developing a systematic method to develop a client’s plan of care.
4. Knowing expected client outcomes.
5. Documenting experience with a nursing documentation system.
Answer: 1. Developing a problem-solving approach to nursing care.
2. Gaining experience in critical thinking skills.
3. Developing a systematic method to develop a client’s plan of care.
4. Knowing expected client outcomes.
Rationale:
Developing a problem-solving approach to nursing care. The assignment will assist the learner in the development of a problem-solving approach to nursing care. Gaining experience in critical thinking. By doing this assignment, the learner will gain experience in critical thinking skills. Developing a systematic method to develop a client’s plan of care. By doing this assignment, the learner will develop a systematic method for devising a client’s plan of care. Knowing expected client outcomes. By doing this assignment, the learner will gain experience in knowing expected client outcomes. Experience with a nursing documentation system. The forms listed to complete in the Preparation for Practice exercises do not include a specific documentation system, although the completion of the assignment will improve documentation skills.
12. The learner will utilize which phases of the nursing process to determine the effectiveness of medications when completing the medication administration record (MAR) when doing a Preparation for Practice exercise?
1. Assessment and evaluation
2. Nursing diagnosing and planning client goals
3. Identifying of problems and nursing diagnosing
4. Implementation and evaluation
Answer: Assessment and evaluation
Rationale:
The medication administration record includes the usual dose, route, frequency, class, and action of the drug, the rationale for administration, side effects with nursing implications, and assessment data that indicate effectiveness. This will help the learner to become familiar with the evaluations necessary to determine effectiveness. The medication administration record form directs the learner to plan for assessing and evaluating for effectiveness but it does not direct the learner to include nursing diagnoses or client goals. The MAR includes the rationale for administration but does not include nursing diagnoses. Side effects with nursing implications and evaluation data for determining effectiveness are to be included, but the form does not specifically require nursing implementation.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
