Fundamental Nursing Skills and Concept 10th Edition Timby -Test Bank

Fundamental Nursing Skills and Concept 10th Edition Timby -Test Bank

1. A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?
A) To transmit health records between insurance companies
B) To investigate the quality of care in the agency
C) To inform family and others concerned about the client’s care
D) To release the entire health record for research
Ans: B
Feedback:
Medical records may occasionally be used to investigate the quality of care in the agency. A medical record is not used to transmit health records between insurance companies, to inform family and others concerned about the client’s care, or to release the entire health record for research, as these actions would jeopardize the individual’s right to privacy.

2. A nurse is caring for a client at the local health care facility. Which of the following ensures that the HIPAA legislation is implemented at the facility?
A) Ensure that the client’s name is displayed on the first page of all faxed records.
B) Put the client’s health information up on a whiteboard to be seen by health care workers.
C) Place light boxes for examining x-rays with the client’s name in private areas.
D) Present end-of-shift reports to the nurse coming on duty in the client’s room.
Ans: C
Feedback:
The nurse should ensure that light boxes for examining x-rays with the client’s name are located in private areas to ensure that HIPAA is implemented at the facility. This will ensure that important client health details are not visible to personnel who are not involved in the client’s health care. HIPAA requires that the client’s name is not displayed on the first page of all faxed records; the first page should indicate that the information in the statement is confidential. The nurse should not put up the client’s health information on a whiteboard to be seen by other health care workers. End-of-shift reports to the nurse coming on duty should not be presented in the client’s room, as there could be relatives of the client in the room with whom the client may not want to share the information.

3. A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports?
A) Speak individually to each staff member before attending the meeting.
B) Wait for the physicians to arrive before exchanging notes.
C) Avoid asking questions related to the medical record.
D) Come prepared with material required to take notes.
Ans: D
Feedback:
The nurse should come prepared with material required to take notes during the change-of-shift reports. The nurse should not delay the meeting for change-of-shift report by speaking to each staff member individually. Change-of-shift reports are not normally conducted in the presence of physicians; hence, the nurse need not wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

4. When maintaining medical records for a client, the nurse knows that a medical record also serves as legally admissible evidence. What should the nurse do to ensure legally defensible charting?
A) Ensure that the client’s name appears on all pages.
B) Leave spaces between entries and signature.
C) Use abbreviations wherever possible.
D) Record all facts and subjective interpretations.
Ans: A
Feedback:
The nurse should ensure that the client’s name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and not use abbreviations wherever possible. The nurse should record all the facts but not any subjective interpretations, to ensure that the document is legal evidence.

5. When documenting information in a client’s medical record, which of the following should the nurse do consistently for each entry?
A) Report each observation to the physician.
B) Sign each entry by name and title.
C) Obtain a signature from the physician.
D) Provide the day of the week on the entry.
Ans: B
Feedback:
When documenting information in a client’s medical record, the nurse should sign each entry by name and title. It is not necessary for the nurse to report every observation to the physician. Obtaining a signature from the physician is not absolutely essential. The nurse need not enter the day of the week for each entry, but the nurse must enter the date and time for each entry.