Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 15
Question 1
Type: MCSA
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. “We’ll 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.”
Question 2
Type: MCSA
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.”
Question 3
Type: MCSA
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
Question 4
Type: MCSA
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.
Question 5
Type: MCSA
When attempting to locate recent lab results, the new nurse employee notices that each department has a separate
section in the client’s chart. Which type of documentation system is the nurse using?
1. Source-oriented record
2. Problem-oriented record
3. Case management
4. Focus charting
Question 6
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 12-hour shift. Which type of charting is this nurse
completing?
1. Problem-oriented recording
2. Source-oriented recording
3. Narrative charting
4. Plan of care
Question 7
Type: MCSA
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
Question 8
Type: MCSA
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
Question 9
Type: MCSA
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
Question 10
Type: MCSA
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
Question 11
Type: MCSA
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
Question 12
Type: MCSA
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.
Question 13
Type: MCSA
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
Question 14
Type: MCSA
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