Chapter 20: Documenting and reporting (Prep U)

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply.

• Sign every entry,

• Document in chronological order

• Identify the day and time for each entry.

• Acknowledge the client's response to the medication.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse? Select all that apply.

• Read back the prescription.

• Record the date and time of the prescription.

• Include V.O. with the health care provider's name on the prescription.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.