Question 1

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)

Accepted Answer

A)  Bypass the firewall. 
B)  Implement an automatic sign-off. 
C)  Create a password with just letters. 
D)  Use a programmed speed-dial key when faxing. 
E)  Impose disciplinary actions for inappropriate access.
F) Shred papers containing personal health information (PHI). 
A)  Bypass the firewall. 
B)  Implement an automatic sign-off. 
C)  Create a password with just letters. 
D)  Use a programmed speed-dial key when faxing. 
E)  Impose disciplinary actions for inappropriate access.
F) Shred papers containing personal health information (PHI). B, D, E, F

Question 2

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?

Accepted Answer

A)  Upon admission 
B)  Right before discharge 
C)  After the congestion is treated 
D)  When the primary care provider writes the order 
A)  Upon admission 
B)  Right before discharge 
C)  After the congestion is treated 
D)  When the primary care provider writes the order A

Question 3

A nurse wants to find the daily weights of a patient. Which form will the nurse use?

Accepted Answer

A)  Database 
B)  Progress notes 
C)  Patient care summary 
D)  Graphic record and flow sheet 
A)  Database 
B)  Progress notes 
C)  Patient care summary 
D)  Graphic record and flow sheet D

Question 4

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete?

Accepted Answer

A)  A verbal report 
B)  An electronic record entry 
C)  A referral 
D)  An acuity rating 
A)  A verbal report 
B)  An electronic record entry 
C)  A referral 
D)  An acuity rating

Question 5

A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally?

Accepted Answer

A)  Charts legibly 
B)  States the patient is belligerent 
C)  Writes entry for another nurse 
D)  Uses correction fluid to correct error 
A)  Charts legibly 
B)  States the patient is belligerent 
C)  Writes entry for another nurse 
D)  Uses correction fluid to correct error

Question 6

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting?

Accepted Answer

A)  Patient went up and down stairs 
B)  Demonstrated use of crutches 
C)  Used crutches with no difficulties 
D)  Deficient knowledge related to never using crutches 
A)  Patient went up and down stairs 
B)  Demonstrated use of crutches 
C)  Used crutches with no difficulties 
D)  Deficient knowledge related to never using crutches

Question 7

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?

Accepted Answer

A)  A minimum data set 
B)  An admission assessment and acuity level 
C)  A focused assessment/specific body system 
D)  An intake assessment form and auditing phase 
A)  A minimum data set 
B)  An admission assessment and acuity level 
C)  A focused assessment/specific body system 
D)  An intake assessment form and auditing phase

Question 8

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym.
-R

Accepted Answer

A) Applied oxygen, stayed with patient, and instructed to slow breathing. 
B) Patient states, "feel better," respirations 16 with O2 saturations 96%. 
C) Patient states, "can't catch my breath and chest hurts." Confused. 
A) Applied oxygen, stayed with patient, and instructed to slow breathing. 
B) Patient states, "feel better," respirations 16 with O2 saturations 96%. 
C) Patient states, "can't catch my breath and chest hurts." Confused.

Question 9

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?

Accepted Answer

A)  Determining the degree to which standards of care are met by reviewing patients' health records 
B)  Realizing that care not documented in patients' health records still qualifies as care provided 
C)  Basing reimbursement upon the diagnosis-related groups documented in patients' records 
D)  Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment 
A)  Determining the degree to which standards of care are met by reviewing patients' health records 
B)  Realizing that care not documented in patients' health records still qualifies as care provided 
C)  Basing reimbursement upon the diagnosis-related groups documented in patients' records 
D)  Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment

Question 10

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record?

Accepted Answer

A)  Nursing process form 
B)  Step-by-step skills manual 
C)  A list of possible procedures 
D)  Reports to third-party payers 
A)  Nursing process form 
B)  Step-by-step skills manual 
C)  A list of possible procedures 
D)  Reports to third-party payers

Question 11

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?

Accepted Answer

A)  Add this data to the problem list. 
B)  Focus chart using the DAR format. 
C)  Document the variance in the patient's record. 
D)  Report a positive variance in the next interdisciplinary team meeting. 
A)  Add this data to the problem list. 
B)  Focus chart using the DAR format. 
C)  Document the variance in the patient's record. 
D)  Report a positive variance in the next interdisciplinary team meeting.

Question 12

A patient is being discharged home. Which information should the nurse include?

Accepted Answer

A)  Acuity level 
B)  Community resources 
C)  Standardized care plan 
D)  Signature for verbal order 
A)  Acuity level 
B)  Community resources 
C)  Standardized care plan 
D)  Signature for verbal order

Question 13

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym.
-A

Accepted Answer

A) Applied oxygen, stayed with patient, and instructed to slow breathing. 
B) Patient states, "feel better," respirations 16 with O2 saturations 96%. 
C) Patient states, "can't catch my breath and chest hurts." Confused. 
A) Applied oxygen, stayed with patient, and instructed to slow breathing. 
B) Patient states, "feel better," respirations 16 with O2 saturations 96%. 
C) Patient states, "can't catch my breath and chest hurts." Confused.

Question 14

A nurse is charting. Which information is critical for the nurse to document?

Accepted Answer

A)  The patient had a good day with no complaints. 
B)  The family is demanding and argumentative. 
C)  The patient received a pain medication, Lortab. 
D)  The family is poor and had to go on welfare. 
A)  The patient had a good day with no complaints. 
B)  The family is demanding and argumentative. 
C)  The patient received a pain medication, Lortab. 
D)  The family is poor and had to go on welfare.

Question 15

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym.
-D

Accepted Answer

A) Applied oxygen, stayed with patient, and instructed to slow breathing. 
B) Patient states, "feel better," respirations 16 with O2 saturations 96%. 
C) Patient states, "can't catch my breath and chest hurts." Confused. 
A) Applied oxygen, stayed with patient, and instructed to slow breathing. 
B) Patient states, "feel better," respirations 16 with O2 saturations 96%. 
C) Patient states, "can't catch my breath and chest hurts." Confused.

Question 16

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?

Accepted Answer

A)  Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. 
B)  Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. 
C)  Breathing without difficulty. Sitting up in bed watching TV. Had a good day. 
D)  Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours. 
A)  Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. 
B)  Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. 
C)  Breathing without difficulty. Sitting up in bed watching TV. Had a good day. 
D)  Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

Question 17

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?

Accepted Answer

A)  Status unchanged, doing well 
B)  Patient seems to be in pain and states, "I feel uncomfortable." 
C)  Left knee incision 1 inch in length without redness, drainage, or edema 
D)  Patient is hard to care for and refuses all treatments and medications. Family is present. 
A)  Status unchanged, doing well 
B)  Patient seems to be in pain and states, "I feel uncomfortable." 
C)  Left knee incision 1 inch in length without redness, drainage, or edema 
D)  Patient is hard to care for and refuses all treatments and medications. Family is present.

Question 18

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up?

Accepted Answer

A)  The new nurse documents only for self. 
B)  The new nurse charts consecutively on every other line. 
C)  The new nurse ends each entry with signature and title. 
D)  The new nurse keeps the password secure. 
A)  The new nurse documents only for self. 
B)  The new nurse charts consecutively on every other line. 
C)  The new nurse ends each entry with signature and title. 
D)  The new nurse keeps the password secure.

Question 19

Which entry will require follow-up by the nurse manager?

Accepted Answer

A)  0800 
B)  0810 
C)  0815 
D)  0830 
A)  0800 
B)  0810 
C)  0815 
D)  0830

Question 20

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

Accepted Answer

A)  12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. 
B)  12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back. 
C)  12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. 
D)  12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN. 
A)  12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. 
B)  12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back. 
C)  12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. 
D)  12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN.

Exam 26: Documentation and Informatics

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?

A nurse wants to find the daily weights of a patient. Which form will the nurse use?

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete?

A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally?

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting?

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym. -R

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record?

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?

A patient is being discharged home. Which information should the nurse include?

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym. -A

A nurse is charting. Which information is critical for the nurse to document?

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym. -D

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up?

Which entry will require follow-up by the nurse manager?

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

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