Question 1

When using electronic (or computerized)documentation,which process should the nurse use to ensure that no one alters the information the nurse has entered?

Accepted Answer

A)  Charting in code 
B)  Logging off 
C)  Charting in privacy 
D)  Signing on with a password 
A)  Charting in code 
B)  Logging off 
C)  Charting in privacy 
D)  Signing on with a password B

Question 2

What makes home health care documentation unique?

Accepted Answer

A)  Some charting is retained at the hospital. 
B)  The health care provider's office needs separate charting. 
C)  Different health care providers need access. 
D)  The health care provider is the pivotal person in the charting. 
A)  Some charting is retained at the hospital. 
B)  The health care provider's office needs separate charting. 
C)  Different health care providers need access. 
D)  The health care provider is the pivotal person in the charting. C

Question 3

The best defense against malpractice claims associated with nursing care is accurate _____________.

Accepted Answer

documentation

Question 4

Who is the legal owner of the patient's medical record?

Accepted Answer

A)  Patient 
B)  Health care provider 
C)  Institution 
D)  State 
A)  Patient 
B)  Health care provider 
C)  Institution 
D)  State

Question 5

A nurse is using the data,action,response,education (DARE)system of charting,and is completing the data portion.What data are the nurse's focus?

Accepted Answer

A)  Planning 
B)  Assessment 
C)  Implementation 
D)  Patient teaching 
A)  Planning 
B)  Assessment 
C)  Implementation 
D)  Patient teaching

Question 6

What does the nurse use as a basis for documentation in focus charting?

Accepted Answer

A)  Problem list 
B)  Nursing orders 
C)  Patient problems 
D)  Evaluation 
A)  Problem list 
B)  Nursing orders 
C)  Patient problems 
D)  Evaluation

Question 7

Documentation is necessary for the evaluation of patient care.Of which phase of the nursing process is this an integral part?

Accepted Answer

A)  Assessment 
B)  Planning 
C)  Implementation 
D)  Evaluation 
A)  Assessment 
B)  Planning 
C)  Implementation 
D)  Evaluation

Question 8

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____________ ________________.

Accepted Answer

The answer of A health care audit that evaluates services...

Question 9

What are some problems associated with electronic (or computerized)charting? (Select all that apply. )

Accepted Answer

A)  Security 
B)  Expense of training staff 
C)  Legibility 
D)  Easy retrieval 
E)  New terminology 
A)  Security 
B)  Expense of training staff 
C)  Legibility 
D)  Easy retrieval 
E)  New terminology

Question 10

A new patient is being admitted to a long-term care facility.Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the patient problem identified?

Accepted Answer

A)  Health care provider 
B)  Registered nurse 
C)  Unlicensed assistive personnel 
D)  Licensed practical nurse/licensed vocational nurse 
A)  Health care provider 
B)  Registered nurse 
C)  Unlicensed assistive personnel 
D)  Licensed practical nurse/licensed vocational nurse

Question 11

Twenty-four-hour charting is designed to establish __________ levels to help determine staffing needs.

Accepted Answer

The answer of Twenty-four-hour charting is designed to establish __________...

Question 12

The nurse charts only additional treatments done,changes in patient condition,and new concerns.What is this system of documentation?

Accepted Answer

A)  SOAP 
B)  Block 
C)  CBE 
D)  Focus 
A)  SOAP 
B)  Block 
C)  CBE 
D)  Focus

Question 13

Why is documentation especially significant in managed care?

Accepted Answer

A)  The hospital needs to show that employees care for patients. 
B)  Institutions are reimbursed only for patient care that is documented. 
C)  Patients might bring lawsuits if care was not given. 
D)  Documents may become part of a lawsuit. 
A)  The hospital needs to show that employees care for patients. 
B)  Institutions are reimbursed only for patient care that is documented. 
C)  Patients might bring lawsuits if care was not given. 
D)  Documents may become part of a lawsuit.

Question 14

Documentation using the DARE format (Data,Action,Response,Education)includes elements of the __________ charting system.

Accepted Answer

The answer of Documentation using the DARE format (Data,Action,Response,Education)includes elements...

Question 15

When documenting an incident in the nurse's notes,what should the nurse include? (Select all that apply. )

Accepted Answer

A)  Description of injury,including diagrams of injury placement 
B)  Date,time,and location of incident 
C)  Name of health care provider and family members notified 
D)  Chronologic order of events of the incident 
E)  Confirmation that an incident report was initiated 
A)  Description of injury,including diagrams of injury placement 
B)  Date,time,and location of incident 
C)  Name of health care provider and family members notified 
D)  Chronologic order of events of the incident 
E)  Confirmation that an incident report was initiated

Question 16

What is the purpose of QA (quality assurance)?

Accepted Answer

A)  To screen employment applications 
B)  To evaluate care results against accepted standards 
C)  To conduct in-services for "quality documentation" 
D)  To report deviation from standards to the state health department 
A)  To screen employment applications 
B)  To evaluate care results against accepted standards 
C)  To conduct in-services for "quality documentation" 
D)  To report deviation from standards to the state health department

Question 17

What should the nurse be sure to do when documenting in a patient's chart?

Accepted Answer

A)  Include speculation. 
B)  Chart consecutively. 
C)  Leave blank spaces. 
D)  Include retaliatory comments. 
A)  Include speculation. 
B)  Chart consecutively. 
C)  Leave blank spaces. 
D)  Include retaliatory comments.

Question 18

What does documentation of type of care,time of care,and signature of the person prove?

Accepted Answer

A)  The person who signed the documentation did all the work noted. 
B)  No litigation can be brought against the person who signed. 
C)  Interventions were implemented to meet the patient's needs. 
D)  The patient's response to the intervention was positive. 
A)  The person who signed the documentation did all the work noted. 
B)  No litigation can be brought against the person who signed. 
C)  Interventions were implemented to meet the patient's needs. 
D)  The patient's response to the intervention was positive.

Question 19

A nurse is receiving a telephone order from a health care provider.The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals.What is the second step of this method?

Accepted Answer

A)  Read back 
B)  Background 
C)  Recommendation 
D)  Situation 
E)  Assessment 
A)  Read back 
B)  Background 
C)  Recommendation 
D)  Situation 
E)  Assessment

Question 20

What is the system that classifies patients by age,diagnosis,and surgical procedure,and produces 300 different categories used for predicting the use of hospital resources?

Accepted Answer

A)  Quality assurance 
B)  Resource assessment 
C)  Quality improvement 
D)  Diagnosis-related groups 
A)  Quality assurance 
B)  Resource assessment 
C)  Quality improvement 
D)  Diagnosis-related groups

Exam 3: Documentation

When using electronic (or computerized)documentation,which process should the nurse use to ensure that no one alters the information the nurse has entered?

What makes home health care documentation unique?

The best defense against malpractice claims associated with nursing care is accurate _____________.

Who is the legal owner of the patient's medical record?

A nurse is using the data,action,response,education (DARE)system of charting,and is completing the data portion.What data are the nurse's focus?

What does the nurse use as a basis for documentation in focus charting?

Documentation is necessary for the evaluation of patient care.Of which phase of the nursing process is this an integral part?

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____________ ________________.

What are some problems associated with electronic (or computerized)charting? (Select all that apply. )

A new patient is being admitted to a long-term care facility.Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the patient problem identified?

Twenty-four-hour charting is designed to establish __________ levels to help determine staffing needs.

The nurse charts only additional treatments done,changes in patient condition,and new concerns.What is this system of documentation?

Why is documentation especially significant in managed care?

Documentation using the DARE format (Data,Action,Response,Education)includes elements of the __________ charting system.

When documenting an incident in the nurse's notes,what should the nurse include? (Select all that apply. )

What is the purpose of QA (quality assurance)?

What should the nurse be sure to do when documenting in a patient's chart?

What does documentation of type of care,time of care,and signature of the person prove?

A nurse is receiving a telephone order from a health care provider.The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals.What is the second step of this method?

What is the system that classifies patients by age,diagnosis,and surgical procedure,and produces 300 different categories used for predicting the use of hospital resources?

The Evolution of Nursing

Legal and Ethical Aspects of Nursing

Communication

Nursing Process and Critical Thinking

Cultural and Ethnic Considerations

Asepsis and Infection Control

Body Mechanics and Patient Mobility

Hygiene and Care of the Patients Environment

Safety

Admission, transfer, and Discharge

Vital Signs

Physical Assessment

Oxygenation

Elimination and Gastric Intubation

Care of Patients Experiencing Urgent Alterations in Health

Dosage Calculation and Medication Administration

Fluids and Electrolytes

Nutritional Concepts and Related Therapies

Complementary and Alternative Therapies

Pain Management, comfort, rest, and Sleep

Surgical Wound Care

Specimen Collection and Diagnostic Testing

Lifespan Development

Loss, grief, dying, and Death

Health Promotion and Pregnancy

Labor and Delivery

Care of the Mother and Newborn

Care of the High-Risk Mother, newborn, and Family With Special Needs

Health Promotion for the Infant, child, and Adolescent

Basic Pediatric Nursing Care

Care of the Child With a Physical and Mental or Cognitive Disorder

Health Promotion and Care of the Older Adult

Concepts of Mental Health

Care of the Patient With a Psychiatric Disorder

Care of the Patient With an Addictive Personality

Home Health Nursing

Long-Term Care

Rehabilitation Nursing

Hospice Care

Introduction to Anatomy and Physiology

Care of the Surgical Patient

Care of the Patient With an Integumentary Disorder

Care of the Patient With a Musculoskeletal Disorder

Care of the Patient With a Gastrointestinal Disorder

Care of the Patient With a Gallbladder, liver, biliary Tract, or Exocrine Pancreatic Disorder

Care of the Patient With a Blood or Lymphatic Disorder

Care of the Patient With a Cardiovascular or a Peripheral Vascular Disorder

Care of the Patient With a Respiratory Disorder

Care of the Patient With an Endocrine Disorder

Care of the Patient With an Endocrine Disorder

Care of the Patient With a Reproductive Disorder

Care of the Patient With a Visual or Auditory Disorder

Care of the Patient With a Neurologic Disorder

Care of the Patient With an Immune Disorder

Care of the Patient With Hivaids

Care of the Patient With Cancer

Professional Roles and Leadership

Filters

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____.