A client is being transferred to a subacute care facility. A printed copy of the electronic medical record is sent with the client. Which documents should be included in the client's legal health record? (SELECT ALL THAT APPLY)
Event/unusual occurrence reports
Physician/nurse practitioner orders
Living will
Vital sign flow records
Proof of residence or deed to their home
Nurses assessments
Correct Answer : B,C,D,F
B. Physician and nurse practitioner orders specify the medical treatments, medications, and interventions prescribed for the client. These orders are essential for guiding care at the subacute care facility and are a critical part of the legal health record.
C. A living will, also known as an advance directive, outlines the client's preferences for medical treatment and care in the event they are unable to communicate their wishes. It is a legal document that guides decision-making regarding end-of-life care.
D. Vital sign flow records document the client's vital signs over time, including measurements such as blood pressure, heart rate, respiratory rate, and temperature. These records are essential for monitoring the client's health status and detecting trends or changes.
F. Nurses' assessments document the nursing observations, assessments, and interventions provided to the client. These assessments are crucial for ongoing nursing care and should be included in the legal health record.
A. Event or unusual occurrence reports document any incidents or deviations from the standard of care that occur during the client's hospitalization. These reports are important for quality improvement and risk management but are typically not included in the legal health record unless they directly impact the client's care.
E. Proof of residence or property ownership documents are not typically included in the legal health record. These documents are unrelated to the client's medical care and are considered personal or administrative records.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1705"]
Explanation
To calculate the cumulative fluid intake for the client from 3 p.m. to 11 p.m., convert all measurements to the same unit and then sum them up.
First, convert ounces to milliliters (1 ounce = 29.5735 ml). The tea is 4 ounces, which is approximately 118 ml, and the soda is 6 ounces, approximately 177 ml.
Add all the liquid intake: chicken broth (120 ml) + tea (118 ml) + ice cream (assumed to be 240 ml for 1 cup) + soda (177 ml) + water (550 ml) + half the volume of ice chips (as half the volume of ice chips is water, so 250 ml). The total intake is 120 + 118 + 240 + 177 + 550 + 500= 1705 ml.
Since the intake and output are calculated at 2200, and the client has not consumed anything after 2115, the cumulative fluid intake for the shift is 1705 ml.
Correct Answer is B
Explanation
B. Teaching preschoolers how to wash their hands correctly is an example of primary prevention. By educating children on proper hand hygiene practices, nurses aim to reduce the spread of infections and promote good health habits. This activity focuses on preventing the transmission of infectious diseases and promoting overall wellness among children
A. Screening for high blood pressure is an example of secondary prevention rather than primary prevention. Secondary prevention involves early detection and treatment to halt or slow down the progress of a disease.
C. Providing hospice care is a form of palliative care that focuses on improving the quality of life for terminally ill clients and their families. It aims to provide comfort and support rather than preventing disease onset. Therefore, it does not fall under primary prevention but rather under supportive care for those with advanced illness.
D. Teaching a client how to self-administer insulin is an example of tertiary prevention. Tertiary prevention involves managing and reducing the impact of a disease that has already occurred. In this case, teaching self-administration of insulin helps manage diabetes, prevent complications, and promote optimal health outcomes for the client.
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