Online Practice Test 15

Your Results for: "NCLEX® Review"

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 15 > NCLEX® Review Date/Time Submitted: July 8, 2012 at 4:04 PM (UTC/GMT)

Summary of Results 80% Correct of 10 Scored items: 8 Correct:  80% 2 Incorrect:  20% More information about scoring

1.		Who is legally entitled to view a client's medical records without written consent? Your Answer: Health care professionals who are caring for the client
		Objective: List the measures used to maintain the confidentiality of client records. Rationale: Health care professionals who are caring for a client are legally entitled to client records. Friends should not have access to the client's records. Insurance company would only be granted access after the client has signed a formal consent. The client's son cannot access the records without signed consent. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Comprehension Strategy: Use nursing knowledge of the law and the process of elimination to make a selection
2.		Which of the following actions by a nurse would endanger the confidentiality of a client's records?  Your Answer: The nurse logs on to the client's file and leaves the computer to answer the client's call light.
		Objective: List the measures used to maintain the confidentiality of client records. Rationale: Logging on to the client's file and leaving the computer to answer the client's call light would allow unauthorized individuals to access the client's records. Closing a file and logging off would protect confidentiality. Refusing to share a computer password would protect confidentiality. Assuring a client diagnosed with AIDS that only the health care team will know the diagnosis would not endanger confidentiality. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Use nursing knowledge of law and the process of elimination to make a selection
3.		Discharge and referral summaries usually include all of the following except: Your Answer: Laboratory and diagnostic studies
		Objective: Discuss reasons for keeping client records. Rationale: Laboratory and diagnostic studies generally are not included in discharge summaries. Documentation of the client's outcome must be included in the final record. Unresolved problems must be listed so that they can be addressed and corrected, either in another institution or on an outpatient basis. Current medications must be listed in order to ensure continuity of care and appropriate follow-up. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Comprehension Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		Which of the following statements best describes a source-oriented record? Your Answer: Information is arranged according to the client's problems. Correct Answer: Each department uses a separate part of the client's chart.
		Objective: Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. Rationale: A source-oriented record is generally considered best when each department uses a separate part of the client's chart. A problem list describes a problem-oriented record. Source-oriented charting is a traditional method. Information is arranged according to problems in a problem-oriented medical record. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Understand contemporary nursing practice.
5.		A major advantage of problem-oriented medical records (POMRs) is that they: Your Answer: Encourage collaboration
		Objective: Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. Rationale: A major advantage of problem-oriented medical records (POMRs) is that they encourage collaboration. POMRs are somewhat inefficient, and are difficult to use to retrieve information. The problem list must be revised and updated frequently in order to implement appropriate care for the client. Caregivers differ in their ability to use POMRs. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Understand contemporary nursing practice.
6.		Which of the following nursing notations is an example of subjective data? Your Answer: Complains of right-sided weakness.
		Objective: Explain how various forms in the client record (e.g., flow sheets, progress notes, care plans, critical pathways, Kardexes, discharge/transfer forms) are used to document steps of the nursing process (assessment, diagnosis, planning, implementation, and evaluation). Rationale: Complains of right-sided weakness is an example of subjective data. Right hand is cool to touch is an objective, measurable finding. Unable to grasp objects with right hand is an objective statement. Gait is unsteady is an objective, measurable finding. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Comprehension Strategy: Understand contemporary nursing practice.
7.		Which of the following statements best describes the PIE charting model? Your Answer: PIE incorporates the care plan into the client's progress notes.
		Objective: Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model. Rationale: PIE incorporates the care plan into the client's progress notes. The PIE charting model does require a review of all nursing notes. PIE uses the terms subjective data, objective data, assessment, planning and describes the components of the SOAP acronym. The SOAP charting model is a supplement to the client's care plan. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Strategy: Understand contemporary nursing practice.
8.		A client is admitted to the hospital with diabetes, a wound infection, and senile dementia. Would a case management model using critical pathways be appropriate for this client? Your Answer: No, because clients with multiple diagnoses are difficult to document on a critical pathway
		Objective: Compare and contrast the documentation needed for clients in acute care, home health care, and long-term care settings. Rationale: A case management model would not be used, because clients with multiple diagnoses are difficult to document on a critical pathway. A physician's order is not required for case management. The client's payer source does not dictate the use of case management. Multiple diagnoses are difficult to track on a critical pathway. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Understand contemporary nursing practice.
9.		Which of the following forms is not used to document nursing activities? Your Answer: Critical pathways Correct Answer: Laboratory reports
		Objective: Identify essential guidelines for reporting client data. Rationale: Laboratory reports are not used in documenting nursing activities. Critical pathways, Kardex, and assessment forms document nursing activities. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Comprehension Strategy: Understand contemporary nursing practice.
10.		How often should a plan of care be revised for long-term care clients? Your Answer: Every three months, or whenever the client's health status changes
		Objective: Compare and contrast the documentation needed for clients in acute care, home health care, and long-term care settings. Rationale: The plan of care should be revised every three months, or whenever the client's health status changes. The care plan does not need to be revised each time a new physician's order is written. The care plan does not need to be revised when medications are changed, unless there is a corresponding change in the client's status. The care plan does not require revision every week unless the client's health status has changed. Nursing Process: Evaluation Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Strategy: Understand contemporary nursing practice, issues, and trends.