Chapter 026

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
colleagues?
1. Audit of client care procedures
2. The clients diagnostic-related group
3. All routine care procedures required by the client
4. Instructions given to the client in a teaching plan
ANS: 4
A change-of-shift report should include instructions given in a teaching plan and the
clients response. This should not include detailed content unless staff members ask for
clarification. The nurse should relay to staff significant changes in the way therapies are
given, but should not describe basic steps of a procedure. The clients 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 report.
2. Details of the incident are subjectively described.
3. An explanation of the possible cause for the incident is entered.
4. A notation is included in the medical record 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
included. 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
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. 1230Clients vital signs taken.
2. 0700Client drank adequate amount of fluids.
Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
26-2
3. 0900Demerol given for lower abdominal pain.

4. 0830Increased IV fluid rate to 100 mL/hr according to protocol.
ANS: 4
Information within a recorded entry needs to be complete, containing appropriate and
essential 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 describe his or her pain or rate it according to a pain scale for comparison later. It
also does not indicate whether the clients pain was in the lower left or lower right
quadrant, or both.
DIF: A
REF: 389
OBJ: Comprehension
4. The nurse makes a late entry in a clients record. Which of the following is the best
example of how to document this type of situation?
1. 2:45 PMASA gr X given for temperature of 38.1 C.
2. 8:30 AMClient received Percodan (1 tablet) PO an hour before going to
radiology.
3. 12:15 PMI gave the client morphine 10 mg IM at 11:10 AM but did not
document it then.
4. 8:30 PMAbdominal 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
action and an objective observation. This notation (8:30 AM) is not complete. It does not
indicate why the Percodan was given. What was the clients level of pain? Where was the
pain located? The nurse does not need to document about herself; only the client. In this
option (12:15 PM), the nurse does not indicate why the morphine was given (clients level
of pain? location of pain?). This entry (8:30 PM) is not complete. It does not state the size
of the wound, type of dressing used, or the clients tolerance of the procedure.
DIF: A
REF: 389
OBJ: Comprehension
5. The following statement: Upon exertion, the client is wheezing and experiencing some
dyspnea, is an example of:
1. The P of PIE
2. FOCUS documentation
3. The R in DAR documentation
4. The S in SOAP documentation
ANS: 1
Test Bank
26-3
These data are examples of the P of PIE because they describe the problem. FOCUS
charting does not concentrate on only problems. It is structured according to a clients
concerns. The R in DAR documentation is the response of the client. This situation
describes the clients problem, not the clients response. The S in SOAP documentation
represents subjective data (verbalizations of the client).
DIF: A
REF: 391
OBJ: Comprehension
6. To locate the recording of a nurses description of the teaching provided to the client on
performance of self-medication administration, one would look in a(n):
1. Kardex
2. Incident report
3. Nursing history form
4. Discharge summary form
ANS: 4
A nurses description of the teaching provided to the client on performance of selfmedication administration is recorded in the discharge summary form. A Kardex is a
written form that contains basic client information. A Kardex contains an activity and
treatment section and a nursing care plan section that organizes information for quick
reference as nurses give change-of-shift report. It does not include a description of
teaching that was provided to the client. An incident report is any event that is not
consistent with the routine operation of a health care unit or routine care of a client (e.g.,
a client falls). A nursing history form guides the nurse through a complete assessment to
identify relevant nursing diagnoses or problems. It provides baseline data about the client.
DIF: A
REF: 397-398
OBJ: Comprehension
7. The nurse has made an error and is documenting such on the clients record and notes.
The action that the nurse should take is to:
1. Draw a straight line through the error and initial it.
2. Erase the error and write over the material in the same spot.
3. Use a dark color marker to cover the error and continue immediately after that
point.
4. Footnote the error at the bottom of the page.
ANS: 1
Test Bank
26-4
If a nurse has made an error in documentation, the nurse should draw a single line
through the error, write the word error above it, and sign his or her name or initials. Then
record the note correctly. The nurse should not erase, apply correction fluid, or scratch
out errors made while recording because charting becomes illegible. Also, entries should
only be made in ink so they cannot be erased. Using a dark color marker to cover the
error is not correct. It may appear as if the nurse was attempting to hide something or
deface the record. Footnotes are not used in nursing documentation.
DIF: A
REF: 388-389
OBJ: Comprehension
8. The new staff nurse is having her documentation evaluated by the charge nurse. On
review of her charting, the charge nurse notes that there is evidence of appropriate
documentation when the new staff nurse:
1. Uses a pencil to make the entries
2. Uses correction fluid to correct written errors
3. Identifies an error made by the attending physician
4. Dates and signs all of the entries made in the record
ANS: 4
Each entry should begin with the time and end with the signature and title of the person
recording the entry. All entries should be recorded legibly and in black ink because pencil
can be erased. The nurse should never erase entries, never use correction fluid, or never
use a pencil. The use of correction fluid could make the charting become illegible and it
may appear as if the nurse were attempting to hide something or to deface the record. If
the physician made an error, the nurse should not document it in the clients chart. It
should be documented in an incident report.
DIF: A
REF: 389
OBJ: Comprehension
9. What is the correct response for the licensed practical nurse that answers the phone to
respond within the following scenario? The physician calls to leave orders late at night
for one of his clients.
1. Let me get the Registered Nurse on the phone.
2. I am unable to take the order at this time. Please call in the morning.
3. Please repeat the order for me so I can make sure it is written correctly.
4. Let me have your phone number and I will have the supervisor call you back.
ANS: 1
Test Bank
26-5
A telephone order involves a physician stating a prescribed therapy over the phone to a
registered nurse. Saying that an order is unable to be taken and to call back in the
morning is not an appropriate response and not in the clients best interest. It is best to
repeat any prescribed orders back to the physician, who can then verify if it is correct or
clarify the order. This is not the appropriate response. A registered nurse needs to take the
verbal order, but it does not have to be the nursing supervisor.
DIF: A
REF: 402
OBJ: Comprehension
10. The client developed a slight hematoma on his left forearm. The nurse labels the problem
as an infiltrated intravenous (IV) line. The nurse elevates the forearm. The client states,
My arm feels better. What is documented as the R in FOCUS charting?
1. Infiltrated IV line
2. My arm feels better
3. Elevation of left forearm
4. Slight hematoma on left forearm
ANS: 2
The R in FOCUS charting is the clients response. In this case, the nurse would
document, My arm feels better. Infiltrated IV line would be documented as D
referring to data in FOCUS charting. Elevation of left forearm is the A in FOCUS
charting. It describes the action or nursing intervention. Slight hematoma on left
forearm is the D referring to data in FOCUS charting.
DIF: A
REF: 391
OBJ: Comprehension
11. Which of the following is evaluated as a legally appropriate notation?
1. Dr. Green made an error in the amount of medication to administer.
2. Verbalized sharp, stabbing pain along the left side of chest.
3. Nurse Williams spoke with the client about the surgery.
4. Client upset about the physical therapy.
ANS: 2
Entries should be concise, factual, and accurate. Verbalized sharp, stabbing pain along
the left side of chest is an example of an objective description of a clients behavior. The
nurse should not document physician made error. Instead, the nurse could chart that
Dr. Green was called to clarify order for medication administration. The nurse should
chart only for himself or herself. In this case, nurse Williams should write the charting
entry. Only objective descriptions of the clients behavior should be recorded. For
example: Client states, I dont want physical therapy! I want to go home!
DIF: A
REF: 388-389
OBJ: Comprehension
Test Bank
26-6

12. To avoid legal risks and possible lack of confidentiality associated with computerized
documentation, many programs currently have:
1. Periodic changes in staff passwords
2. Thumbprint identification restrictions
3. All nursing staff uses the same access code
4. Only centralized medical records use the client data
ANS: 1
A good system of computerized documentation requires periodic changes in personal
passwords to prevent unauthorized persons form tampering with records. Many programs
do not have thumbprint identification restrictions. All nurses do not use the same access
code. Each nurse should have his or her own password. Only centralized medical records
using the client data is not a true statement. Authorized health care providers from any
department can access and use the data.
DIF: A
REF: 406
OBJ: Comprehension
13. Which of the following nursing statements reflects the best understanding of the role of
documentation and the Medicare reimbursement policy?
1. Medicare reviews client charts to determine care given.
2. Good charting results in good Medicare reimbursement.
3. Our nursing salaries are paid for by the Medicare reimbursement funds.
4. The hospital is reimbursed for the nursing care documented in the client chart.
ANS: 4
Under the prospective payment system, Medicare reimburses hospitals a set dollar
amount for each diagnosis-related group (DRG). Everything that is done for a client must
be documented in the medical record for the health care institution to recover its costs.
DIF: C
REF: 387
OBJ: Analysis
TOP: Nursing Process: Implementation
14. The professional nurse realizes there is both a legal and an ethical obligation to keep
client information obtained through examination, observation, conversation, or treatment:
1. Secured
2. Accessible
3. Confidential
4. Documented
ANS: 3
Test Bank
26-7
Nurses are legally and ethically obligated to keep information about clients confidential.
Nurses may not discuss a clients examination, observation, conversation, or treatment
with other clients or staff not involved in the clients care. The other options are primarily
directed towards written records and are not ethically oriented.
DIF: A
REF: 385
OBJ: Comprehension
TOP: Nursing Process: Planning
15. Which of the following nursing statements regarding the release of a clients medical
record to another institution requires immediate follow-up by the nurses manager?
1. Im pretty sure this will require the clients permission.
2. Are you sure of the exact policy? Do you know what I should do?
3. The client agreed to the consultation, so Ill have the chart sent over.
4. I think the client will need to give a verbal consent before it can be sent.
ANS: 3
Each institution has policies to control the manner for sharing records. In most situations,
clients are required to give written permission for release of medical information. The
other options have the nurse asking for help or expressing doubt about the proper
protocol for the release of the records; these would be appropriate statements and the
manager should provide the correct information.
DIF: C
REF: 385
OBJ: Analysis
16. Regarding access to client records, the nursing faculty informs the nursing students to be
prepared to:
1. Show the unit staff proper student identification
2. Sign a confidentiality agreement when on the unit to preplan
3. Review the medical record only in the presence of unit staff
4. Obtain permission from the client to access his or her medical record
ANS: 1
When nurses and other health care professionals have a legitimate reason to use records
for data gathering, research, or continuing education, they obtain appropriate
authorization according to agency policy. Nursing students and faculty may be required
to present identification indicating access to the record is authorized. The remaining
options are not required if the student is properly identified and shows need to access the
material.
DIF: C
REF: 385
OBJ: Analysis
Test Bank
26-8
17. Which of the following nursing actions is most directly aimed at affording a client
confidential treatment of his or her medical information while minimizing delay in
accessing needed medical and nursing care?
1. Notifying the client of the institutions privacy policy
2. Denying nonessential personal access to the clients medical records
3. Acquiring the clients verbal consent to share his or her medical record with
essential personnel
4. Requiring that the client sign the Health Insurance Portability and Accountability
Act (HIPAA) form
ANS: 1
Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in
order to eliminate barriers that could delay access to care, required only that health care
providers notify clients of their privacy policy and make a reasonable effort to get written
acknowledgment of this notification.
DIF: A
REF: 385
OBJ: Comprehension
18. When another health care professional is asked to assess a client for the purpose of
suggesting treatment to the primary health care provider, this is called a:
1. Referral
2. Consultation
3. Transfer report
4. Multidisciplinary meeting
ANS: 1
Referrals are the request for services by another care provider usually for the purpose of
determining appropriate client care. Consultations are a form of discussion whereby one
professional caregiver actually gives formal advice about the care of a client to another
caregiver. The remaining options are methods of exchanging general information
regarding a client.
DIF: A
REF: 386
OBJ: Comprehension
19. Which of the following nursing notations shows the best understanding regarding the
need to document only objective client assessment data?
1. Client was angry because breakfast was not to her liking.
2. Client is depressed; was observed crying while alone in room.
3. Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen
and clenching her fists.
4. Client was verbally abusive to staff when approached concerning clients
continued attempts to smoke in the bathroom.
ANS: 3
Test Bank
26-9
Do not write personal opinions. Document observable, measurable client-oriented data

only. The remaining options either make assumptions regarding observed client behavior
or fail to objectively describe the noted client behavior.
DIF: C
REF: 388-389
OBJ: Analysis
20. Which of the following nursing notations shows the greatest need for instruction
regarding the need to document only objective client assessment data?
1. Client was angry because breakfast was not to her liking.
2. Client is depressed; was observed crying while alone in room.
3. Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen
and clenching her fists.
4. Client was verbally abusive to staff when approached concerning clients
continued attempts to smoke in the bathroom.
ANS: 2
Do not write personal opinions. Document observable, measurable client-oriented data
only. Recording that the client is depressed based on the observation of tears is not
objective and so is not acceptable. While one option does report only observable,
measurable behavior, the remaining options, while noting observed client behavior, do
fail to objectively describe the noted client behavior.
DIF: C
REF: 388-389
OBJ: Analysis
TOP: Nursing Process: Assessment
21. Which of the following statements made by a nurse most reflects a need for additional
instruction on areas of client care requiring nursing documentation?
1. The fact that the client refused the prescribed antidepressant medication was noted
in his chart.
2. I provided a detailed description of the dressing change in the clients chart in
order to show it was done as prescribed.
3. The clients wife told me he often develops a rash when he comes into contact
with scented soaps, so I noted that in his chart.
4. I had a long conversation with the client concerning his fears about his upcoming
surgery and I mentioned his concerns in my nursing note.
ANS: 2
Common charting mistakes that can result in malpractice include the following: (1)
failing to record pertinent health or drug information; (2) failing to record nursing
actions; (3) failing to record that medications have been given; (4) failing to record drug
reactions or changes in clients condition; (5) writing illegible or incomplete records; and
(6) failing to document a discontinued medication. Detailed descriptions of procedures
are not included in the nursing notes.
Test Bank
26-10
DIF: C
REF: 388
OBJ: Analysis
22. The nursing faculty recognizes the correct way to instruct the nursing students to
acknowledge their charting in a clients medical record is:
1. James Thicket, NS, WVU
2. J. Jones, NS, Montclair Shores College
3. N.H, SN, Bellfield City Community College
4. Linda Mozden, SN, Fairmont State University
ANS: 4
A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and
educational institution, such as David Jones, SN (student nurse), CMTC (Central Maine
Technical College).
DIF: A
REF: 389
OBJ: Comprehension
23. The nurse realizes that the incorrect spelling of terms in the medical record most
importantly:
1. Shows a lack of competency
2. Displays little attention to detail
3. Contributes to serious treatment errors
4. Negatively affects the accuracy of the documentation
ANS: 3
Spelling errors can result in serious treatment errors; for example, the names of certain
medications such as digitoxin and digoxin or morphine and Numorphan are similar.
Misspelling such terms can result in medication errors that may cause serious harm to a
client. The other options are correct but do not have the seriousness of client care errors.
DIF: C
REF: 389
OBJ: Analysis
24. Related to Problem Oriented Medical Record (POMR) documentation, which of the
following statements made by a nurse reflects the greatest need for additional instruction
on the proper management of a resolved client problem?
1. His surgery corrected the mobility problem, so I drew a line through it and dated
it.
2. The clients problem list has several resolved problems on it; should I take them
off?
3. The client no longer has anxiety issues so I highlighted that problem on his
problem list.
4. He doesnt experience any dizziness now that we have his medication regulated,
Test Bank
26-11
so Ive erased that from his problem list.

ANS: 4
New problems are added as they are identified. When a problem has been resolved,
record the date and highlight it or draw a line through the problem and its number.
Erasure is not an acceptable method of showing that a problem has been resolved.
DIF: A
REF: 390-391
OBJ: Comprehension
25. Which of the following is an example of a problem statement used in the ProblemIntervention-Evaluation documentation method?
1. Risk for injury related to falling due to dizziness
2. Client fell while walking to bathroom unassisted
3. Client continues to report periods of dizziness upon sitting up
4. Educated to the purpose of dangling on the bedside before standing
ANS: 1
The problem is reflected by a nursing diagnosis while the interventions are related to
nursing actions directed toward minimizing or eliminating the problem. The evaluation is
the clients objective or subjective response to the nursing intervention.
DIF: A
REF: 391
OBJ: Comprehension
26. Which of the following is an example of an intervention used in the ProblemIntervention-Evaluation documentation method?
ANS: 4
DIF: A
REF: 391
OBJ: Comprehension
27. Related to Problem Oriented Medical Record (POMR) documentation, which of the
following statements made by a nurse reflects the greatest need for additional instruction
on the proper management of a resolved client problem?
1. His surgery corrected the mobility problem, so I draw a line through it and dated
it.
Test Bank
26-12
2. The clients problem list has several resolved problems on it; should I take them
off?
3. The client no longer has anxiety issues so I highlighted that problem on his
problem list.
4. He doesnt experience any dizziness now that we have his medication regulated, so
Ive erased that from his problem list.
ANS: 4
New problems are added as they are identified. When a problem has been resolved,
record the date and highlight it or draw a line through the problem and its number.
Erasure is not an acceptable method of showing that a problem has been resolved.
DIF: A
REF: 387
OBJ: Comprehension
28. Which of the following is an example of a problem statement used in the ProblemIntervention-Evaluation documentation method?
ANS: 1
DIF: A
REF: 385
OBJ: Comprehension
29. Which of the following is an example of an intervention used in the ProblemIntervention-Evaluation documentation method?
3. Client continues to report periods of dizziness on sitting up
ANS: 4
DIF: A
REF: 390
OBJ: Comprehension
Test Bank
26-13
MULTIPLE RESPONSE
1. Nursing documentation should fulfill which of the following criteria? (Select all that
apply.)
1. Accurate
2. Inclusive
3. Well organized
4. Show continuity of care
5. Record nursing opinion
6. Identify client outcomes
ANS: 1, 2, 3, 4, 6
Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve
critical data, maintain continuity of care, track client outcomes, and reflect current
standards of nursing practice. Nursing documentation should include nursing
observations, not nursing opinions.
DIF: C
REF: 390-391
OBJ: Analysis
2. The nurse realizes that effective nursing documentation encourages: (Select all that
apply.)
1. Safe nursing practice
2. Continuity of client care
3. Positive client outcomes
4. Efficient time management
5. Cost-conscious nursing care
6. Effective nurse-client relationships
ANS: 1, 2, 4
Effective documentation ensures continuity of care, saves time, and minimizes the risk of
errors. While important, the remaining options are not criteria for effective nursing
documentation.
DIF: C
REF: 391
OBJ: Analysis
3. Problem Oriented Medical Record (POMR) method of documentation includes which of
the following sections? (Select all that apply.)
1. Database
2. Care plan
3. Evaluations
4. Problem list
5. Interventions
Test Bank
26-14
6. Progress notes
ANS: 1, 2, 4, 6
The POMR has the following major sections: database, problem list, care plan, and
progress notes. Interventions and evaluations are documentation sections related to PIE
(Problem, Interventions, and Evaluation) charting.
DIF: A
REF: 391
OBJ: Comprehension

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Chapter 026

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Copyright:

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Potter & Perry: Fundamentals of Nursing, 7th Edition

3. 0900Demerol given for lower abdominal pain.

MSC: NCLEX test plan designation: Safe, Effective Care Environment

Do not write personal opinions. Document observable, measurable client-oriented data

so Ive erased that from his problem list.

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