CHAPTER 15 NCLEX QUESTIONS REVIEWER

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as it’s his record. How should
the nurse respond to this client’s request?
1. You’ll have to ask your doctor for permission to do that.
2. Actually, the original record is the property of the hospital, but you are welcome to copies of your records.
3. Well make sure that all of your records are sent ahead to the rehab hospital, so you don’t really have to worry about those details.
4. There’s a new law that protects your records, so you’re not going to be able to have access to them.

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why it’s permissible for
them to review and have access to client records in the clinical area. How should the nursing instructor respond?
1. Confidentiality and privacy laws don’t apply to students.
2. Most students review so many records and charts that they could not possibly remember details from any one of them.
3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict
confidence.
4. As long as the clinical instructor is in the area, accessing client records is part of the education process.

The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been
implemented to help ensure the security of client records?
1. A firewall to protect the server from unauthorized access
2. One unit password to protect the unit’s information
3. Expectation to log off a terminal after using it
4. Expectation to turn the monitor away from view when unattended
5. Requirement to shred all computer-generated worksheets

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with
chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of
reimbursement?
1. The client’s record contained an incorrect DRG.
2. The client was charged for an ECG.
3. A code cart was opened and the client was charged for medications opened but not used.
4. The physician made a diagnostic mistake.

When attempting to locate recent lab results, the new nurse employee notices that each department has a separate section in the
clients chart. Which type of documentation system is the nurse using?
1. Source-oriented record
2. Problem-oriented record
3. Case management
4. Focus charting
The nurse makes chronological entries in a client’s chart that include documentation about the routine care provided, assessment
findings, and client problems during a 12hour shift. Which type of charting is this nurse completing?
1. Problem-oriented recording
2. Source-oriented recording
3. Narrative charting
4. Plan of care

The nurse is reviewing a client’s chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the
most recent physician orders?
1. Database
2. Problem list
3. Plan of care
4. Progress notes

A client has specific cultural needs that affect the plan of care. In which part of the client’s problem-oriented medical record should the
nurse document this information?
1. Database
2. Problem list
3. Plan of care
4. Progress notes

The client states: I really don’t want anyone to visit me who has not been cleared by me first. If utilizing SOAP format, in which category
should the nurse document this statement?
1. Subjective data
2. Objective data
3. Assessment
4. Planning

The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse
document this information?
1. Plan
2. Intervention
3. Evaluation
4. Progress notes

The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system
is the nurse using?
1. Computerized documentation
2. Focus charting
3. SOAP charting
4. Charting by exception
The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require
care in all of the areas identified on a flow sheet. What action should the nurse take?
1. Leave the areas blank.
2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart.
3. Write N/A on the flow sheet in the areas that are not applicable to that client.
4. Make sure this information gets passed along in the shift report.

A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager
using a critical pathway should identify this outcome as being which of the following?
1. An unattainable goal
2. A variance
3. An error in care planning
4. An error in intervention implementation

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and
nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of
form is this hospital utilizing?
1. Standardized care plans
2. Traditional care plans
3. Critical pathways
4. Kardex

Before providing care, the nurse reviews the client’s pertinent history, daily treatments, diagnostic procedures, allergies, problems, and
other information. Which form should the nurse review to learn all of this information?
1. The client’s medical record
2. The MAR (medication administration record)
3. The written care plan
4. The Kardex

The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client?
1. Lasix, 20 mg, po bid
2. Lasix, 20 mg tablet, twice daily
3. Lasix, 20 mg by mouth, two times a day a day
4. Lasix, 20 mg by mouth 8 AM and 2 PM

A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document
this information?
1. MDS
2. OBRA
3. CBE
4. Kardex
When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should
the nurse document for this finding?
1. Client fell out of bed, but did push the call button for assistance.
2. Client became tangled in the bed linens, then called for assistance after falling out of bed.
3. Recorder responded to clients call light, upon entering the room, found client on floor.
4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.

After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the
wrong medical record. What should the nurse do?
1. Use white-out over the mistake.
2. Take a wide permanent marker and blacken out all the documentation.
3. Put an X through the entire page, identify it as an error, initial, and move on to the correct chart.
4. Draw a single line through the documentation, write mistaken entry next to the original entry, and initial it.

The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting
in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system?
Standard Text: Select all that apply.
1. The system is relatively inexpensive to maintain.
2. Bedside terminals eliminate worksheets and note taking.
3. The system links to various sources of client information.
4. The system better protects client privacy.
5. Information is legible.
6. Results, requests, and client information can be sent and received quickly.