Exam 4: Documentation and Informatics

Nursing documentation must have which of the following characteristics? (Select all that apply.)

Which of the following provides a quick,easy reference for health care team members in assessing the patient's status,and includes specific measurements such as vital signs,intake and output,and pain assessment?

The unregulated care provider (UCP)tells the registered nurse (RN)that when the patient's vital signs were taken,the patient complained that she was in a lot of pain.The UCP then tells the nurse that she charted the patient's complaint when she charted the vital signs.What instruction does the nurse need to provide to the nursing assistant?

Which of the following is the best example of objective charting?

The nurse manager is attempting to determine the staffing needs of the unit.One tool that she may use to determine the level of care needed would be

The patient has been in the hospital for a hip replacement.According to his critical pathway,he should have his Foley catheter discontinued on the fourth day after surgery.Instead,the patient has it removed on the third day and is voiding normally with no problems.This would be a sign of

Nursing documentation (Select all that apply.)

Which of the following should be documented at the time of occurrence? (Select all that apply.)

Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000 hours.At 1000,a patient complains of feeling "light-headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.How should the nurse handle documentation for this episode?

The patient is ready to go home from the hospital.What does the nurse provide to the patient and his family before he leaves the facility?

Which of the following must be complied with when using the electronic health record (EHR)?

Which is a primary difference between care in the community and hospital care?

Multidisciplinary care plans that include key interventions and expected outcomes within an established time frame are known as _______________.

Standardized care plans (SCPs)are effective ways to plan care for the patient.To be most effective,however,the SCP must be _________________.

The patient is a 24-year-old man who is diagnosed with possible human immunodeficiency virus (HIV)infection while being treated for active pneumonia.He has stated that the nurse may share test result information with his significant other but nothing else at this time.With whom may the nurse communicate regarding this information?

Which of the following is the best example of accurate documentation?

A preprinted guideline used to care for patients with similar health problems is known as the

The patient was in bed with all side rails up.During the night,the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient was not harmed,what step should the nurse take (if any)?