A nurse is reviewing the record system used in an agency.

Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals?

(Select all that apply.).

Kardexes.

Flow sheets.

Progress notes.

Nursing discharge summaries.

Care plan conferences.

Answer and Explanation

Correct Answer : A,B

Kardexes and flow sheets are types of records that are used for documenting concise data about a client and making information quickly accessible to all health professionals. Kardexes are a series of cards kept in a portable index file or on computer generated forms that contain a problem list, stated goals and list of nursing approaches to meet the goals. Flow sheets are forms that allow for recording routine aspects of care such as vital signs, intake and output, medications, etc.

Choice C is wrong because progress notes are not concise, but rather narrative descriptions of the client’s condition, interventions and outcomes. Choice D is wrong because nursing discharge summaries are not used for quick access, but rather for providing information about the client’s hospitalization, treatment and follow-up care. Choice E is wrong because care plan conferences are not records, but meetings where health professionals discuss the client’s needs, goals and progress.

Normal ranges for vital signs are as follows:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respiration: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mmHg.

Nursing Test Bank

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Correct Answer is B

Explanation

It allows access to client information from multiple locations.

This is an advantage of using a computerized system for documentation and reporting because it enables health care providers to access relevant and updated information about their clients from different locations, such as hospitals, clinics, or home care settings.This can improve the quality and continuity of care, as well as facilitate communication and collaboration among different members of the health care team.

Choice A is wrong because it is not true that a computerized system eliminates errors and inaccuracies in documentation.While a computerized system can reduce some types of errors, such as illegible handwriting or misplaced files, it can also introduce new types of errors, such as data entry mistakes, software glitches, or system failures.

Choice C is wrong because it is not true that a computerized system reduces the need for verbal or written communication among health care providers.On the contrary, a computerized system can enhance communication by allowing health care providers to share information more easily and quickly, but it does not replace the need for verbal or written communication to clarify, confirm, or discuss the information.

Choice D is wrong because it is not true that a computerized system protects client information from unauthorized disclosure or alteration.

While a computerized system can provide some security features, such as passwords, encryption, or audit trails, it can also pose some risks, such as hacking, phishing, or malware attacks.Therefore, health care providers need to follow ethical and legal guidelines to ensure the confidentiality and integrity of client information in a computerized system.

A. Specifies the plan of care for clients with different diagnoses. B. Provides guidelines for managing clients with similar health problems. C. Describes the roles and responsibilities of each member of the health care team. D. Evaluates the quality and cost-effectiveness of care delivered to clients.

Correct Answer is B

Explanation

A critical pathway provides guidelines for managing clients with similar health problems.According to the definition from Wikipedia, a critical pathway is one of the main tools used to manage the quality in healthcare concerning the standardisation of care processes.It has been shown that their implementation reduces the variability in clinical practice and improves outcomes.

Choice A is wrong because a critical pathway does not specify the plan of care for clients with different diagnoses, but rather for a specific group of patients with a predictable clinical course.Choice C is wrong because a critical pathway does not describe the roles and responsibilities of each member of the health care team, but rather defines, optimizes and sequences the different tasks (interventions) by the professionals involved in the patient care.Choice D is wrong because a critical pathway does not evaluate the quality and cost-effectiveness of care delivered to clients, but rather aims to promote organised and efficient patient care based on evidence-based medicine.

Normal ranges for COPD are: FEV1/FVC ratio < 0.7; FEV1 < 80% predicted; FVC normal or reduced; TLC > 80% predicted; RV > 120% predicted; DLCO < 80% predicted.

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A nurse is reviewing the record system used in an agency. Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is one advantage of using a computerized system for documentation and reporting?

Correct Answer is B

Explanation

A nurse is reviewing a critical pathway for a client who has chronic obstructive pulmonary disease (COPD). The nurse should understand that a critical pathway:.

Correct Answer is B

Explanation

A nurse is using CBE documentation for a client who has diabetes mellitus. The nurse administers insulin to the client and documents this on a:.

A nurse is reviewing the record system used in an agency. Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals? (Select all that apply.).

A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following abbreviations should the nurse use? (Select all that apply.).

A nurse is using SOAP format to document a client’s progress note. What does SOAP stand for?

A nurse is documenting the care provided to a client who receives home health services. Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?

A nurse is teaching a newly hired nurse about the legal aspects of documentation. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is preparing to document the admission nursing assessment for a client who has pneumonia. Which of the following information should the nurse include in this documentation?

A nurse is reviewing the record system used in an agency.

Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals?

(Select all that apply.).