SL Mosby Quizzes

Question 1

The client’s chart is a legal document and admissible in court as evidence of the client’s care.

a. ) Education b.) Reimbursement
c. ) Research d.) Legal documentation
e. ) Communication f.) Auditing Health Agency
g. ) Health Care Analysis

Answer 1

d.) Legal documentation

Question 2

The diagnosis-related group (DRG) codes facilitates payment through the federal government, such as Medi-cal and Medicare.

a. ) Education b.) Reimbursement
c. ) Research d.) Legal documentation
e. ) Communication f.) Auditing Health Agency
g. ) Health Care Analysis

Answer 2

b.) Reimbursement

Question 3

Which of the following actions by a nurse ensures confidentiality of a client’s PHI?

a. ) The nurse discusses the client’s plan of care in the elevator with a colleague.
b. ) The nurse puts the Medication Administration Record (MAR) back in the chart after passing the 0900 medications.
c. ) The nurse logs on to the client’s file and leaves the computer unattended while the nurse answers the client’s call light.
d. ) The nurse takes a picture of the client’s open abdominal wound with the nurse’s cell phone while the client sleeps.

Answer 3

b.) The nurse puts the Medication Administration Record (MAR) back in the chart after passing the 0900 medications.

Question 4

The information contained in a record can yield information helpful in treating other clients.

a. ) Education b.) Reimbursement
c. ) Research d.) Legal documentation
e. ) Communication f.) Auditing Health Agency
g. ) Health Care Analysis

Answer 4

c.) Research

Question 5

Students in health care disciplines often use client records to learn and adapt from.

a. ) Education b.) Reimbursement
c. ) Research d.) Legal documentation
e. ) Communication f.) Auditing Health Agency
g. ) Health Care Analysis

Answer 5

a.) Education

Question 6

A vehicle by which different health professionals who interact with a client communicate with each other.

a. ) Education b.) Reimbursement
c. ) Research d.) Legal documentation
e. ) Communication f.) Auditing Health Agency
g. ) Health Care Analysis

Answer 6

e.) Communication

Question 7

Information provided in client’s charts allow health care planners to analyze what generates revenue and what depletes revenue.

a. ) Education b.) Reimbursement
c. ) Research d.) Legal documentation
e. ) Communication f.) Auditing Health Agency
g. ) Health Care Analysis

Answer 7

g.) Health Care Analysis

Question 8

A review of a client record for quality-assurance purposes, such as The Joint Commission.

a. ) Education b.) Reimbursement
c. ) Research d.) Legal documentation
e. ) Communication f.) Auditing Health Agency
g. ) Health Care Analysis

Answer 8

f.) Auditing Health Agency

Question 9

Apply calamine lotion Q12 hrs & prn.

a. ) Objective
b. ) Assessment
c. ) Subjective
d. ) Plan

Answer 9

d.) Plan

Question 10

Skin on left elbow erythematous with lichenification.

a. ) Objective
b. ) Assessment
c. ) Subjective
d. ) Plan

Answer 10

a.) Objective

Question 11

“My elbow is so itchy since that bandage was removed.”

a. ) Objective
b. ) Assessment
c. ) Subjective
d. ) Plan

Answer 11

c.) Subjective

Question 12

Altered comfort related to pruritis.

a. ) Objective
b. ) Assessment
c. ) Subjective
d. ) Plan

Answer 12

b.) Assessment

Question 13

It is important to organize narrative charting in an organized, coherent manner in order to present the client’s problems and responses to interventions.

a. ) true
b. ) false

Answer 13

a.) true

Question 14

SBARR is a framework that healthcare providers use to effectively communicate information regarding a client’s condition. Which of the following information describes the assessment portion of SBARR:

a. ) Would you like me to increase his neurological checks to every 2 hours?
b. ) The client was admitted on 4/8/13 following a MVA.
c. ) The client fell on the floor at 2300.
d. ) The client’s vitals are: BP 122/80, P 78, RR 14, T.98.7F, Pain 6/10. No LOC.

Answer 14

d.) The client’s vitals are: BP 122/80, P 78, RR 14, T.98.7F, Pain 6/10. No LOC.

Question 15

The client’s plan of care includes:

a. ) Collected documentation of all team members providing care for the client.
b. ) Physician orders, demographic data, and medication administration and rationales.
c. ) Client’s nursing diagnoses, goals, expected outcomes, and the nursing interventions.
d. ) Client assessment data, medical treatment regime and rationales, and diagnostic test results and significance.

Answer 15

c.) Client’s nursing diagnoses, goals, expected outcomes, and the nursing interventions.

Question 16

It is important to fill out flowsheets completely because blank spaces imply that an assessment or intervention was not completed, attempted or recognized.

a. ) true
b. ) false

Answer 16

a.) true

Question 17

By mouth.

a. ) ADL
b. ) prn
c. ) TID
d. ) BRP
e. ) po

Answer 17

e.) po

Question 18

As needed.

a. ) ADL
b. ) prn
c. ) TID
d. ) BRP
e. ) po

Answer 18

b.) prn

Question 19

Bathroom priviledges.

a. ) ADL
b. ) prn
c. ) TID
d. ) BRP
e. ) po

Answer 19

d.) BRP

Question 20

Activities of daily living.

a. ) ADL
b. ) prn
c. ) TID
d. ) BRP
e. ) po

Answer 20

a.) ADL

Question 21

Three times a day.

a. ) ADL
b. ) prn
c. ) TID
d. ) BRP
e. ) po

Answer 21

c.) TID

Question 22

Which of the following charting rules will keep the nurse legally safe? SELECT ALL THAT APPLY.

a. ) Document worries or concerns expressed by the client.
b. ) Perform most of the charting at the end of the shift.
c. ) Use military time.
d. ) Record only information that pertains to the client’s health problems and care.

Answer 22

a. ) Document worries or concerns expressed by the client.
c. ) Use military time.
d. ) Record only information that pertains to the client’s health problems and care.