A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests." When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:
"Blood not drawn because tests are no longer desired by patient."
"Refuses to have blood drawn; says tests are 'useless. Doctor notified."
"Doctor notified of failure to draw ordered blood work."
"Refuses to have blood drawn. Doctor notified."
The Correct Answer is B
A. "Blood not drawn because tests are no longer desired by patient."
This statement is vague and lacks specific details regarding the patient's exact refusal and the communication with the doctor.
B. "Refuses to have blood drawn; says tests are 'useless.' Doctor notified."
This response documents the patient's refusal with their exact words ("useless") and also notes that the doctor has been informed, which is essential for clear, complete documentation.
C. "Doctor notified of failure to draw ordered blood work."
This documentation lacks the reason for the blood draw failure (patient refusal) and omits the patient’s specific wording.
D. "Refuses to have blood drawn. Doctor notified."
Although this documents the refusal and the doctor’s notification, it omits the patient’s exact words, which can provide additional context for the healthcare team.
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Correct Answer is A
Explanation
A. Guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal. Protecting patient confidentiality is essential in electronic charting to prevent unauthorized access.
B. Learning the passwords of the staff nurses and primary care providers so that they can communicate with one another. Sharing or learning others' passwords violates security protocols and confidentiality rules.
C. Choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation. In facilities using electronic charting, all staff are typically required to use the system to maintain consistent, accessible records.
D. Patient education to input information about herself, such as intake and output or symptoms the patient may experience. Patients typically do not have access to chart directly into their medical records.
Correct Answer is A
Explanation
A. The nurse-patient relationship ends when the patient is discharged.
The nurse-patient relationship is time-limited and often ends when the patient is discharged, which aligns with its structured, goal-oriented nature.
B. A social relationship does not have goals or needs to be met. While social relationships may not have structured goals, they can still have mutual needs or goals. In contrast, the nurse-patient relationship has specific health-related goals and objectives focused on patient care.
C. The focus is mainly on the nurse in the nurse-patient relationship. This is incorrect, as the primary focus of the therapeutic relationship is on the patient's needs and well-being, not the nurse’s.
D. A social relationship does not require trust or sharing of life experiences. Social relationships do require trust and sharing of experiences; however, they are typically not bound by the professional boundaries, goals, and time limitations that define the nurse-patient relationship.