Question 1

The nurse identifies which statement to be accurate regarding the process of making a change-of-shift report (handoff)?

Accepted Answer

A)  Handoff is an uncommon occurrence of little importance. 
B)  Handoff occurs only at change of shift and only to oncoming nurses. 
C)  Handoff can lead to patient death if done incorrectly. 
D)  Handoff does not allow for collaboration or problem solving. 
A)  Handoff is an uncommon occurrence of little importance. 
B)  Handoff occurs only at change of shift and only to oncoming nurses. 
C)  Handoff can lead to patient death if done incorrectly. 
D)  Handoff does not allow for collaboration or problem solving.

Question 2

The nurse understands which statement about the use of electronic health records is true?

Accepted Answer

A)  They improve patient health status. 
B)  They require a keyboard to enter data. 
C)  They have not reduced medication errors. 
D)  They require increased storage space. 
A)  They improve patient health status. 
B)  They require a keyboard to enter data. 
C)  They have not reduced medication errors. 
D)  They require increased storage space.

Question 3

What fact is the nurse aware of when charting using paper nursing notes?

Accepted Answer

A)  Use red ink so the nursing entries stand out. 
B)  When mistakes are made in documentation, the nurse should white out the entry. 
C)  Only one nurse should document on a sheet so that it can be removed in case of error. 
D)  The medical record, in any format, is the most reliable source of information in a legal action. 
A)  Use red ink so the nursing entries stand out. 
B)  When mistakes are made in documentation, the nurse should white out the entry. 
C)  Only one nurse should document on a sheet so that it can be removed in case of error. 
D)  The medical record, in any format, is the most reliable source of information in a legal action.

Question 4

If a verbal or phone order is necessary in an emergency, the nurse knows what action needs to be completed?

Accepted Answer

A)  The order must be taken by an RN or LPN. 
B)  The order must be repeated verbatim to confirm accuracy. 
C)  The order is documented as a written order. 
D)  The order does not need further verification by the provider. 
A)  The order must be taken by an RN or LPN. 
B)  The order must be repeated verbatim to confirm accuracy. 
C)  The order is documented as a written order. 
D)  The order does not need further verification by the provider.

Question 5

When the patient has had a fall while trying to climb out of bed, the nurse must carry out which task?

Accepted Answer

A)  Complete an incident report as a risk management document. 
B)  Complete an incident report and add it to the medical record. 
C)  Document that an incident report was completed in the medical record. 
D)  Say nothing about the incident in the medical record. 
A)  Complete an incident report as a risk management document. 
B)  Complete an incident report and add it to the medical record. 
C)  Document that an incident report was completed in the medical record. 
D)  Say nothing about the incident in the medical record.

Exam 10: Documentation, Electronic Health Records, and Reporting

The nurse identifies which statement to be accurate regarding the process of making a change-of-shift report (handoff)?

The nurse understands which statement about the use of electronic health records is true?

What fact is the nurse aware of when charting using paper nursing notes?

If a verbal or phone order is necessary in an emergency, the nurse knows what action needs to be completed?

When the patient has had a fall while trying to climb out of bed, the nurse must carry out which task?

Nursing, Theory, and Professional Practice

Values, Beliefs, and Caring

Communication

Critical Thinking in Nursing

Introduction to the Nursing Process

Assessment

Nursing Diagnosis

Planning

Implementation and Evaluation

Ethical and Legal Considerations

Leadership and Management

Evidence-Based Practice and Nursing Research

Health Literacy and Patient Education

Nursing Informatics

Health and Wellness

Human Development: Conception Through Adolescence

Human Development: Young Adult Through Older Adult

Vital Signs

Health History and Physical Assessment

Ethnicity and Cultural Assessment

Spiritual Health

Public Health, Community-Based, and Home Health Care

Human Sexuality

Safety

Asepsis and Infection Control

Hygiene and Personal Care

Activity, Immobility, and Safe Movement

Skin Integrity and Wound Care

Nutrition

Cognitive and Sensory Alterations

Stress and Coping

Sleep

Diagnostic Testing

Medication Administration

Pain Management

Perioperative Nursing Care

Oxygenation and Tissue Perfusion

Fluid, Electrolytes, and Acid-Base Balance

Bowel Elimination

Urinary Elimination

Death and Loss

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