Chapter 16 Documenting, Reporting, Conferring, and Using Informatics

Chapter 16  Documenting, Reporting, Conferring, and Using Informatics

Complete Chapter Questions And Answers
 

Sample Questions

1.
A client’s diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client’s chart should be written as …
A)
Avelox (moxifloxacin) 400 mg daily
B)
Avelox (moxifloxacin) 400 mg Q.D.
C)
Avelox (moxifloxacin) 400 mg qd
D)
Avelox (moxifloxacin) 400 mg OD
Ans:
A

Feedback:

Among the JCAHO’s list of “do not use” abbreviations are Q.D., qd, and OD when denoting a once-per-day drug administration. Because of the potential for misinterpretation and consequent drug errors, the JCAHO recommends writing “daily” in the order.

2.
The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?
A)
Vulnerability to legal liability since nurse’s safe, routine care is not recorded
B)
Increased workload for nurses in order to complete necessary documentation
C)
Failure to identify and record client problems and associated interventions
D)
Significant differences in the charting between nurses due to lack of standardization
Ans:
A

Feedback:

A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

3.
The nurse managers of a home health care office wish to maximize nurses’ freedom to characterize and record client conditions and situations in the nurses’ own terms. Which of the following documentation formats is most likely to promote this goal?
A)
Narrative notes
B)
SOAP notes
C)
Focus charting
D)
Charting by exception
Ans:
A

Feedback:

One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

4.
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse’s following statements would appear at the beginning of a charting entry?
A)
“Client complaining of abdominal pain rated at 8/10.”
B)
“Client is guarding her abdomen and occasionally moaning.”
C)
“Client has a history of recent abdominal pain.”
D)
“2 mg Dilaudid PO administered with good effect”
Ans:
A

Feedback:

The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse’s objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

5.
What is the nurse’s best defense if a client alleges nursing negligence?
A)
Testimony of other nurses
B)
Testimony of expert witnesses
C)
Client’s record
D)
Client’s family
Ans:
C

Feedback:

The client record is the only permanent legal document that details the nurse’s interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence.