Exam 3: Documentation and Informatics

At 0915 the nurse repeatedly instructs the patient to remain in bed.At 0930 the nurse enters the patient's room, finds the patient on the floor, and hears the patient say, "I need pain medicine." Which should the nurse do to document this event?

Nursing assistive personnel (NAP) finds a patient on the floor 30 minutes after the patient ambulated with physical therapy.What information should be charted by the NAP on the incident report?

The nurse runs into a co-worker whose family friend is a patient on the unit.The co-worker asks about the friend's health problems.Which is the correct response by the nurse?

An incident report is completed as a result of the pharmacy sending the wrong medication to the unit, even though the medication wasn't administered.A student asks the nurse why this was needed.What response by the nurse is best?

The nursing staff are assisting nursing students in learning military time for documenting.Instruction by the nurses has been effective if the students identify that which entry reflects 40 minutes after midnight?

The nurse discovers a medication error on another nurse's documentation, so the nurse completes an incident report.Which statement should the nurse include in the report?

The nursing staff have been using the SBAR format to structure communication for the past few months.Successful implementation of this system would be present if the nurse manager made which statement?

The nurse is documenting on a patient with a respiratory problem.Which patient datum documented by the nurse is the least objective?

The nurse is documenting the care of a patient.Which entry would be characteristic of charting by exception (CBE) as a documentation method?

The nurse is providing home care for a patient with an infection that is not improving.The patient refuses to see an infectious disease specialist.What should the nurse include in the documentation of the patient teaching provided?

Electronic health records (EHRs) can improve patient care.The following is an example of an alert in an EHR.(Select all that apply.)

In a POMR charting method of documentation, which of the following items are used? (Select all that apply.)

The Joint Commission standards require all patients admitted to a health care agency to have the following documented.(Select all that apply.)

A nurse passes by a computer screen that has patient information that can be seen by visitors.What is the appropriate action for the nurse to take at this time?

The following is an excerpt of a discharge planning note.What elements of discharge planning are present in this example? (Select all that apply.) "Discussed learning about insulin injection technique.Patient will administer his own injection next time."

The following is an example of what part of the SBAR communication mnemonic? "Her blood pressure has decreased from 140/90 to 100/50 and she vomited 400 mL of bright red blood."