Fundamental "Coopers" Exam 1 PDF

Exam 1 fundemental “COOPERS” Chapter 1 What is a nursing program considered when certified by a state agency? a. Accredited b. Approved c. Provisional d. Exemplified ANS: B Approved means certified by a state agency for having met minimum standards; accredited means certified by the NLN for having...

Exam 1 fundemental “COOPERS” Chapter 1 What is a nursing program considered when certified by a state agency? a. Accredited b. Approved c. Provisional d. Exemplified ANS: B Approved means certified by a state agency for having met minimum standards; accredited means certified by the NLN for having met more complex standards. Provisional and exemplified are not terms used in regard to nursing program certification. Which of the following must the nurse recognize regarding the health care delivery system? a. It includes all states. b. It affects the illness of patients. c. Insurance companies are not involved. d. The major goal is to achieve optimal levels of health care. ANS: D The nurse must recognize that in the health care delivery system, the major goal is to achieve optimal levels of health care. The health care system consists of a network of agencies, facilities, and providers involved with health care in a specified geographic area. Insurance companies do have involvement in the health care system. The illness of patients is not necessarily affected by the health care system. What is required by the health care team to identify the needs of a patient and to design care to meet those needs? a. The Kardex b. The health care provider's order sheet c. An individualized care plan d. The nurse's notes ANS: C An individualized care plan involves all health care workers and outlines care to meet the needs of the individual patient. The Kardex, health care provider's order sheet, and nurse's notes do not identify the needs of the patient nor are they designed to assist all members of the health care team to meet those needs Patient care emphasis on wellness, rather than illness, begins as a result of: a. increased education concerning causes of illness. b. improved insurance payments. c. decentralized care centers. d. increased number of health care givers. ANS: A The acute awareness of preventive medicine has resulted in today's emphasis on education about issues such as smoking, heart disease, drug and alcohol abuse, weight control, and mental health and wellness promotion activities. This preventive education has resulted in an emphasis on wellness, rather than illness. Improved insurance payments, decentralized care centers, and increased numbers of health care givers did not influence an emphasis on wellness. What is the most effective process to ensure that the care plan is meeting the needs of the patient? a. Documentation b. Communication c. Evaluation d. Planning ANS: B Communication is the primary essential component among the health care team to evaluate and modify the care plan. Documentation, evaluation, and planning are not primary essential components to ensure the care plan is meeting the needs of the patient. How does an interdisciplinary approach to patient treatment enhance care? a. By improving efficiency of care b. By reducing the number of caregivers c. By preventing the fragmentation of patient care d. By shortening hospital stay ANS: C An interdisciplinary approach prevents fragmentation of care. An interdisciplinary approach does not improve the efficiency of care, reduce the number of caregivers, or shorten hospital stay. How may a newly licensed LPN/LVN practice? a. Independently in a hospital setting b. With an experienced LPN/LVN c. d. Under the supervision of a health care provider or RN As a sole health care provider in a clinic setting ANS: C An LPN/LVN practices under the supervision of a health care provider, dentist, OD, or RN. Whose influence on nursing practice in the 19th century was related to improvement of patient environment as a method of health promotion? a. Clara Barton b. Linda Richards c. Dorothea Dix d. Florence Nightingale ANS: D The influence of Florence Nightingale was highly significant in the 19th century as she fought for sanitary conditions, fresh air, and general improvement in the patient environment. Clara Barton developed the American Red Cross in 1881. Linda Richards is known as the first trained nurse in America, was responsible for the development of the first nursing and hospital records, and is credited with the development of our present-day documentation system. Dorothea Dix was the pioneer crusader for elevation of standards of care for the mentally ill and superintendent of female nurses of the Union Army. What document identifies the roles and responsibilities of the LPN/LVN? a. NLN Accreditation Standards b. Nurse Practice Act c. NAPNE Code d. American Nurses' Association Code ANS: B The LPN/LVN functions under the Nurse Practice Act. NLN Accreditation Standards, the NAPNE Code, and the American Nurses' Association Code do not identify the roles and responsibilities of the LPN/LVN. Whose influence on nursing practice in the 19th century was related to improvement of patient environment as a method of health promotion? a. Clara Barton b. Linda Richards c. Dorothea Dix d. Florence Nightingale ANS: D The influence of Florence Nightingale was highly significant in the 19th century as she fought for sanitary conditions, fresh air, and general improvement in the patient environment. Clara Barton developed the American Red Cross in 1881. Linda Richards is known as the first trained nurse in America, was responsible for the development of the first nursing and hospital records, and is credited with the development of our present-day documentation system. Dorothea Dix was the pioneer crusader for elevation of standards of care for the mentally ill and superintendent of female nurses of the Union Army. What document identifies the roles and responsibilities of the LPN/LVN? a. NLN Accreditation Standards b. Nurse Practice Act c. NAPNE Code d. American Nurses' Association Code ANS: B The LPN/LVN functions under the Nurse Practice Act. NLN Accreditation Standards, the NAPNE Code, and the American Nurses' Association Code do not identify the roles and responsibilities of the LPN/LVN. What is a cost-effective delivery of care used by many hospitals that allows the LPN/LVN to work with the RN to meet the needs of patients? a. Focused nursing b. Team nursing c. Case management d. Primary nursing ANS: C Case management is a cost-effective method of care. Focused nursing, team nursing, and primary nursing are not cost-effective methods of delivering care that allow the LPN/LVN to work with the RN to meet patient needs. What is the title of the American Hospital Association's 1972 document that outlines the patient's expectations to be treated with dignity and compassion? a. Code of Ethics b. Patient's Bill of Rights c. OBRA d. Advance directives ANS: B Patient expectations are outlined by the Patient's Bill of Rights. Patient expectations are not outlined in the Code of Ethics, OBRA, or advance directives. The relationships among nursing, patients, health, and the environment are the basis for: a. care plans. b. nursing models. c. health care provider's orders. d. evaluation of patient care. ANS: B Nursing models are theories based on the relationship between nursing, patients, health, and environment. Care plans, health care provider's orders, and evaluation of patient care are not based on the relationships among nursing, patients, health, and environment. What system reduces the number of employees but still provides quality care for patients? a. Team nursing b. Cross-training c. Use of critical pathways d. Case management ANS: B Cross-training reduces the number of employees but does not alter the quality of patient care. Team nursing, use of critical pathways, and case management do not reduce the number of employees while continuing to provide quality care for patients What is the purpose of licensing laws for LPN/LVNs? a. To limit the number of LPN/LVNs b. Prevention of malpractice c. Protection of the public from unqualified people d. To increase revenue for the state board of nursing ANS: C The purpose of licensing laws for LPN/LVNs is to protect the public from unqualified health care providers. Licensing laws' purpose is not to limit the number of LPNs/LVNs, prevent malpractice, or increase revenue for the state board of nursing. What premise is Maslow's hierarchy of needs based on? a. All needs are equally important. b.Basic needs must be met before the next level of needs can be met. c. Self-actualization is a primary need. d. Individuals prioritize needs the same way. ANS: B Maslow's hierarchy of needs is based on the premise that basic needs must be met first. It is not based on all needs being equally important or that individuals prioritize needs the same way. Self-actualization is not a primary need according to Maslow. What must the nurse realize when assessing physical and social environmental factors affecting health and illness? a. They affect one another. b. They cause illness. c. They cause patients to react similarly. d. They can be separated. ANS: A Physical and social factors affect each other, cannot be separated, and cause each patient to react in a unique manner. They do not necessarily cause illness or cause patients to react similarly, and they cannot be separated. What organization, established during World War II, provided nursing education and training? a. Nightingale school b. Cadet Nurse Corps c. Public health department d. Frontier Nursing ServicE ANS: B The Cadet Nurse Corps was established during World War II to provide nursing education and training. The Nightingale school, public health department, and Frontier Nursing Service are not organizations established during World War II to provide nursing education and training. Where did Florence Nightingale's original nursing education take place? a. Saint Thomas b. Kings College Hospital c. Crimean Hospital d. Kaiserswerth School ANS: D Florence Nightingale trained at Kaiserswerth School. Florence Nightingale's original training was not at Saint Thomas, Kings College Hospital, or Crimean Hospital. What must the nurse realize when assessing physical and social environmental factors affecting health and illness? a. They affect one another. b. They cause illness. c. They cause patients to react similarly. d. They can be separated. ANS: A Physical and social factors affect each other, cannot be separated, and cause each patient to react in a unique manner. They do not necessarily cause illness or cause patients to react similarly, and they cannot be separated. What organization, established during World War II, provided nursing education and training? a. Nightingale school b. Cadet Nurse Corpsc. c. Public health department d. Frontier Nursing Service ANS: B The Cadet Nurse Corps was established during World War II to provide nursing education and training. The Nightingale school, public health department, and Frontier Nursing Service are not organizations established during World War II to provide nursing education and training. What is a modern educational advancement program for the LPN/LVN to enter RN education? a. Repetition b. Exclusion c. Articulation d. Coexistence ANS: C Most states have some type of articulation program in which the LPN/LVN can achieve advanced standing in an RN program without having to enroll in the entire curriculum. Repetition, exclusion, and coexistence do not refer to educational advancement. Where did Florence Nightingale's original nursing education take place? a. Saint Thomas b. Kings College Hospital c. Crimean Hospital d. Kaiserswerth School ANS: D Florence Nightingale trained at Kaiserswerth School. Florence Nightingale's original training was not at Saint Thomas, Kings College Hospital, or Crimean Hospital. What system of comprehensive patient care considers the physical, emotional, and social environment and spiritual needs of a person? a. Interdependent care b. Holistic health care c. Illness prevention care d. Health promotion care ANS: B Holistic health care encompasses the physical, emotional, social, and spiritual aspects of the patient. What official agency exists exclusively for LPN/LVN membership and promotes standards for the LPN/ LVN? a. NFLPN b. ANA c. NLN d. NAPNES ANS: A The NFLPN exists solely for the LPN/LVN. The other options have membership that includes RNs and the lay public. What score does the graduate practical nurse require to be issued a license upon completion of the computerized examination? a. 70% or better b. This is defined and set by each state c. Designated as ―pass‖ d. Within the 75th percentile ANS: C Currently graduates of an approved vocational school are eligible to take the licensing examination and be awarded a license with a score of ―pass‖ that is recognized by all states. What document, published in 1965 by the ANA, clearly defined two levels of nursing practice? a. Licensing standards b. Position paper c. Smith-Hughes Act d. Nurse practice act ANS: B The ANA's position paper of 1965 defined two levels of nursing: registered nurse and technical nurse. Licensing standards, the Smith-Hughes Act, and the nurse practice act were not documents defining two levels of nursing practice published in 1965. What is the wellness/illness continuum defined as? a. A concept that never changes b. The range of a person's total health c. A continuum influenced only by one's physical condition d. An idea that focuses strictly on an individual's social well-being ANS: B The wellness/illness continuum is defined as the range of a person's total health. This continuum is ever changing, and it is influenced by the individual's physical condition, mental condition, and social well-being. According to Maslow's hierarchy of needs, what is an individual's most basic need? a. Safety and security b. Love/belongingness c. Physiologic d. Self-actualization e. Esteem ANS: C Abraham Maslow believed that an individual's behavior is formed by the individual's attempts to meet essential human needs, which he identified as physiologic, safety and security, love and belongingness, and esteem and self-actualization. Florence Nightingale established a nursing school at Saint Thomas Hospital in London. What was it characterized by? (Select all that apply.) a. Allowing all applicants who applied to be enrolled b. Offering formal and practical educational experiences c. Keeping records of students' progress d. Focusing on sanitation and hygiene e. Retaining a registry of all graduates ANS: B, C, D, E The nursing school established by Florence Nightingale rigorously screened its applicants. The curriculum, which included both formal education and practical experiences, was focused on hygiene and sanitation. The school kept records of the students' progress during their school years, and also kept a registry of the graduates. During early civilization bad spirits to leave the body of the ailing person. men performed witchcraft and rituals to induce the Medicine men performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person during early civilization. The National Council of State Boards of Nursing (NCSBN) performs a job analysis every years to determine the scope of practice of LPN/LVNs. ANS: 3 three The National Council of State Boards of Nursing performs a job analysis every 3 years to measure the scope of practice for LPN/LVNs. Graduates of the first school for training the practical nurse were referred to as nurses. ANS: attendant Lillian. ANS: Kuster In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by Lillian Kuster. This association is the official membership organization for licensed practical nurses/licensed vocational nurses (LPN/LVNs), and membership is limited to LPNs and LVNs. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an appropriate court. What is this document called? a. Deposition b. Appeal c. Complaint d. Summons ANS: C A document called a complaint is filed in an appropriate court as the first step in litigation. A deposition is when witnesses are required to undergo questioning by the attorneys. An appeal is a request for a review of a decision by a higher court. A summons is a court order that notifies the defendant of the legal action. The nurse caring for a patient in the acute care setting assumes responsibility for a patient's care. What is this legally binding situation? a. Nurse-patient relationship b. Accountability c. Advocacy d. Standard of care ANS: A When the nurse assumes responsibility for a patient's care, the nurse-patient relationship is formed. This is a legally binding ―contract‖ for which the nurse must take responsibility. Accountability is being responsible for one's own actions. An advocate is one who defends or pleads a cause or issue on behalf of another. Standards of care define acts whose performance is required, permitted, or prohibited. What are the universal guidelines that define appropriate measures for all nursing interventions? a. Scope of practice b. Advocacy c. Standard of care d. Prudent practice ANS: C4. 5. 6. Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on behalf of another. Prudent is a term that refers to careful and/or wise practice. What are the universal guidelines that define appropriate measures for all nursing interventions? a. Scope of practice b. Advocacy c. Standard of care d. Prudent practice ANS: C4. 5. 6. Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on behalf of another. Prudent is a term that refers to careful and/or wise practice. A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of: a. malpractice. b. harm to the patient. c. negligence. d. failure to follow the nurse practice act. ANS: A The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The nurse practice act has general guidelines that can support the charge of malpractice. Patients have expectations regarding the health care services they receive. To protect these expectations, which of the following has become law? a. American Hospital Association's Patient's Bill of Rights b. Self-Determination Act c. American Hospital Association's Standards of Care d. The Joint Commission's rights and responsibilities of patients ANS: A Patients have expectations regarding the health care services they receive. In 1972, theAmerican Hospital Association (AHA) developed the Patient's Bill of Rights. The Self- Determination Act, American Hospital Association's Standards of Care, and The Joint Commission's rights and responsibilities do not address patients' expectations regarding health care The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? a. Physical assessment b. Interview c. Informed consent d. Surgical checklist ANS: C The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure. When a nurse protects the information in a patient's record, what ethical responsibility is the nurse fulfilling? a. Privacy b. Disclosure c. Confidentiality d. Absolute secrecy ANS: C The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action? a. Cover the bruises with bandages. c. Take photographs of the bruises. d. Ask the patient if anyone has hit her. e. Report the bruises to the charge nurse. ANS: D The law stipulates that the health care professional is required to report certain information to the appropriate authorities. The report should be given to a supervisor or directly to the police, according to agency policy. When acting in good faith to report mandated information (e.g., certain communicable diseases or gunshot wounds), the health care professional is protected from liability What is the best way for a nurse to avoid a lawsuit? a. Carry malpractice insurance. b. d. Spend time with the patient. c. Provide compassionate, competent care. d. Answer all call lights quickly. ANS: C The best defense against a lawsuit is to provide compassionate and competent nursing care. Carrying malpractice insurance is prudent, but it will not avoid a lawsuit. Spending time with patients and answering call lights quickly will not necessarily help avoid a lawsuit The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her legal obligation? a. To question the health care provider b. To seek advice from the family c. To discuss it with the patient d. To follow the order ANS: D When a DNR order is written in the chart, the nurse has a duty to follow the order. Questioning the health care provider, seeking advice from the family, and discussing it with the patient are not legal obligations of the nurse The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take? a. Ask for another assignment. b. Leave work. c. Transfer to another floor. d. Protest to the supervisor. ANS: A The nurse should not abandon the patient, but ask for another assignme The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information? a. Nurse practice act b. Standards of care c. Scope of nursing practiced. d. Professional organizations Ans:B Standards of care define what should or should not be done for patients. The nurse practice act, scope of nursing practice, and professional organizations do not provide the best information as to what should or should not be done for patients. What role is the nurse who diligently works for the protection of patients' interests playing? a. Caregiver b. Health care administrator c. Advocate d. Health care evaluator ANS: C A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patient's interests. Caregiver, health care administrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patient When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself? a. Go ahead and do it. b. Refuse to perform it, citing lack of knowledge. c. Discuss it with the charge nurse, asking for direction. d. Ask another nurse who has performed the procedure. ANS: C The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse? a. Compare values with those of the patient. b. Make a judgment. c. Withhold an opinion. d. Give advice. ANS: C The nurse can assist the patient in values clarification without giving an opinion. What fundamental principle must the nurse first observe when confronted with an ethical decision? a. Autonomy b. Beneficence c. Respect for people d. Nonmaleficence ANS: C The first fundamental principle is respect for people. Autonomy, beneficence, and nonmaleficence are not the first fundamental principles to observe when confronted with an ethical decision. A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the patient's health, safety, and well-being. Given this knowledge, which of the following is most necessary for the nurse to report? a. Unethical behavior of other staff members b. A worker who arrives late c. Favoritism shown by nursing administration d. Arguments among the staff ANS: A A member of the nursing profession must report behavior that does not meet established standards. Unethical behavior involves failing to perform the duties of a competent caring nurse A nurse is considering purchasing malpractice insurance. What should the nurse be aware of regarding malpractice insurance provided by the hospital? a. Only offers protection while on duty. b. Is limited in the amount of coverage. c. Is difficult to renew. d. Can be terminated at any time. ANS: A facility. Most institutional insurance only provides liability coverage if the nurse is on duty at that facility. Which is a nursing care error that violates the Health Insurance Portability and AccountabilityAct (HIPAA)? a. Administering a stronger dose of drug than was ordered b. Refusing to give a patient's daughter information over the phone c. Informing the patient's medical power of attorney of a medication change d. Leaving a copy of the patient's history and physical in the photocopier ANS: D Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. Refusing to give a patient's daughter information over the phone is appropriate practice. Which of the following could cause a nurse to be cited for malpractice? a. Refusing to give 60 mg of morphine as ordered b. Giving prochlorperazine (Compazine) to a patient allergic to phenothiazines c. Dragging an injured motorist off the highway and causing further injury d. Informing a visitor about a patient's condition ANS: B Standards of care dictate that a nurse must be aware of all the properties of drugs administered. Prochlorperazine (Compazine) is a phenothiazine. Providing confidential information or refusing to give an excessively large narcotic dose is not considered malpractice. Good Samaritan laws generally protect a person giving aid to an injured motorist A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for: a. punitive damages. b. civil battery. c. assault. d. nothing; no violation has occurred. ANS: B Civil battery charges can be brought against someone performing an invasive procedure without the patient's informed consent legally documented. This patient could not sue for punitive damages or an assault. A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurse's actions exemplify? a. Malpractice b. Battery c. Assaultd. d. Neglect of duty ANS: A A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient What is true about nurse practice acts? a. They informally define the scope of nursing practice. b. They provide for unlimited scope of nursing practice. c. Only some states have adopted a nurse practice act. d. The nurse must know the nurse practice act within his or her state. ANS: D The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurse's responsibility to know the nurse practice act that is in effect for her geographic region. 2. How can the medical record be used in litigation? (Select all that apply.) a. Public record b. Proof of adherence to standards c. Evidence of omission of care d. Documentation of time lapses e. Evidence by only the plaintiff ANS: A, B, C, D The information when used in court becomes a public record. The information can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document. During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.) a. HIPAA violation b. Slander c. Libel d. Invasion of privacye. Defamation ANS: A, D The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libe A nurse failed to monitor a patient's respiratory status after medicating the patient with a narcotic analgesic. The patient's respiratory status worsened, requiring intubation. The patient's family claimed the nurse committed malpractice. What must be present for the nurse to be held liable? (Select all that apply.) a. A nurse-patient relationship exists. b. The nurse failed to perform in a reasonable manner. c. There was harm to the patient. d. The nurse was prudent in her performance. e. The nurse did not cause the patient harm. f. Duty does not exist. ANS: A, B, C For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred 1. Personal beliefs about the worth of an object, idea, custom, or attitude that influence a person's behavior in a given situation are referred to as. ANS: values Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influence our behavior in a given situation. Acts whose performance is required, permitted, or prohibited are defined by of care. ANS: Standards of care define acts whose performance is required, permitted, or prohibited. What does documentation of type of care, time of care, and signature of the person prove? a. The person who signed the documentation did all the work noted. b. No litigation can be brought against the person who signed. c. Interventions were implemented to meet the patient's needs. d. The patient's response to the intervention was positive. ANS: C Documenting type of care, time of care, and signature of the person results in recording the interventions that are implemented to meet the patient's needs. Many charting entries include health care provider's visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive. Why is documentation especially significant in managed care? a. The hospital needs to show that employees care for patients. b. Institutions are reimbursed only for patient care that is documented. c. Patients might bring lawsuits if care was not given. d. Documents may become part of a lawsuit. ANS: B Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs): a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation? a. SOAP b. Block c. CBE d. Focus ANS: C Charting additional treatments done, changes in a patient's condition, and new concern during the shift is charting by exception (CBE) What form explains the lapse when events are not consistent with facility or national standards of expected care? a. Subjective data b. Focus chart c. Incident report d. Nursing assessment ANS: C An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a: a. nursing order. b. Kardex. c. nursing care plan. d. critical pathway. ANS: D Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type. What makes home health care documentation unique? a. Some charting is retained at the hospital. b. The health care provider's office needs separate charting. c. Different health care providers need access. d. The health care provider is the pivotal person in the charting. ANS: C Home health care documentation has unique problems because of the need for different health care workers to access the medical record. What regulates standards for long-term care documentation? a. OBRA b. Title XXIIc. c. Patient problems d. The care plan ANS: A OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record? a. Provide information only to another nurse. b. Provide information only to an attorney. c. Share information only with the family. d. Have a clinical reason for reading the record. ANS: D The nurse should not read the patient's medical record unless there is a clinical reason for doing so. Documentation is necessary for the evaluation of patient care. Which of the following phases of the nursing process is necessary for the evaluation of patient care? a. Assessment b. Planning c. Implementation d. Evaluation ANS: C Documentation is part of the implementation phase of the nursing process. What does the nurse use as a basis for documentation in focus charting? a. Problem list b. Nursing orders c. Patient problems d. Evaluation ANS: C In focus charting, instead of using the problem list, modified patient problems are used as an index for nursing documentation. What is the purpose of QA (quality assurance) a. To screen employment applications b. To evaluate care results against accepted standards c. To conduct in-services for ―quality documentation‖ d. To report deviation from standards to the state health department ANS: B QA is an in-house department that evaluates care services and results against accepted standards What is the process used to appraise the practice of an individual nurse known as? a. Quality assurance b. Incident reporting c. OBRA d. Peer review ANS: D Peer review is an in-house department study that may appraise the nursing practice of individual nurses. What is the documentation format that uses the acronym SOAPE? a. Problem-oriented b. Focused c. Traditional d. Crisis ANS: A The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems. Who is the legal owner of the patient's medical record? a. Patient b. Health care provider c. Institution d. State ANS: C Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the health care provider in the case of private office visits When using electronic (or computerized) documentation, which process should the nurse us to ensure that no one alters the information the nurse has entered? a. Charting in code b. Logging off c. Charting in privacy d. Signing on with a password ANS: B Logging off closes the computer file that was opened with the nurse's password. Any other data entry will require that person to sign on with their password What is the system that classifies patients by age, diagnosis, and surgical procedure, and produces 300 different categories used for predicting the use of hospital resources? a. Quality assurance b. Resource assessment c. Quality improvement d. Diagnosis-related groups ANS: D Cost reimbursement rates under government plans are based on diagnosis-related groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay. A nurse is using the data, action, response, education (DARE) system of charting, and is completing the data portion. What data are the nurse's focus? a. Planning b. Assessment c. Implementation d. Patient teaching ANS: B DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E). A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified. a. Health care provider b. Registered nurse c. Unlicensed assistive personnel d. Licensed practical nurse/licensed vocational nurse ANS: B The registered nurse (RN) has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified. Which of the following will the nurse implement when an error is made when documenting in a patient's chart? a. Scratch out the error. b. Apply correction fluid. c. Erase the error completely. d. Draw a single line through the error. ANS: D A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patient's chart. Instead, the nurse should draw a single line through the error, write the word ―error‖ above it, and sign her name or initials. What should the nurse be sure to do when documenting in a patient's chart? a. Include speculation. b. Chart consecutively. c. Leave blank spaces. d. Include retaliatory comments. ANS: B A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurse's notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line. A nurse is receiving a telephone order from a health care provider. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the second step of this method? a. Read back b. Background c. Recommendation d. Situation e. Assessment ANS: B SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation (Kaiser Permanente, 2007). SBAR is considered a safety measure in preventing errors from poor communication during ―hand-off‖ or ―handover‖ interactions, the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient. An additional ―R‖ is added. The additional ―R‖ (SBARR) represents ―read back‖ when the nurse reads back the order for clarification. What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.) a. Incorrectly recording the time of an event b. Failing to record verbal orders c. Charting events in advance d. Documenting an incorrect date e. Marking out and initialing charting errors ANS: A, B, C, D Marking out with a single line and initialing is an acceptable method to indicate a charting error. What are the basic purposes of written patient records? (Select all that apply.) a. Teaching b. Legal record of care c. Written communication d. Research and data collection e. Permanent record for accountability f. Temporary record of hospitalization ANS: A, B, C, D, E There are five basic purposes for written patient records: (1) written communication, (2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5) research and data collection. What should a medical record provide for all health care providers? (Select all that apply.) a. Care given to the patient b. Care planned for the patient c. A patient's nursing problems d. A patient's medical problems e. Details about any incident reports f. The patient's response to treatment ANS: A, B, C, D, F A medical record should furnish all health care providers with a concise, accurate, written picture of a patient's medical and nursing problems, care planned and given, and the patient's response to treatments. The best defense against malpractice claims associated with nursing care is accurate 2.. ANS: documentation Accurate documentation can guard against malpractice claims because it should describe when, what, and how events occurred. 3. Documentation using the DARE format (Data, Action, Response, Education) includes elements of the charting system. 4. ANS focused Focused charting uses the acronym DARE to direct and formalize charting. A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as. ANS: quality assurance quality assessment quality improvement Quality assurance/assessment/improvement is an audit in health care that evaluates services provided and the results achieved compared with accepted standards.