Question 1

Which behaviors indicate that the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)?

Accepted Answer

A)  Writes the patient's room number and date of birth on a paper for school 
B)  Prints/copies material from the patient's health record for a graded care plan 
C)  Reviews assigned patient's record and another unassigned patient's record 
D)  Reads the progress notes of assigned patient's record 
E)  Gives a change-of-shift report to the oncoming nurse about the patient
F) Discusses patient care with the hospital volunteer 
A)  Writes the patient's room number and date of birth on a paper for school 
B)  Prints/copies material from the patient's health record for a graded care plan 
C)  Reviews assigned patient's record and another unassigned patient's record 
D)  Reads the progress notes of assigned patient's record 
E)  Gives a change-of-shift report to the oncoming nurse about the patient
F) Discusses patient care with the hospital volunteer

Question 2

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement within and across facilities.Which task did the nurse just complete?

Accepted Answer

A)  A focused assessment/specific body system 
B)  The Resident Assessment Instrument/Minimum Data Set 
C)  An admission assessment and acuity level 
D)  An intake assessment form and auditing phase 
A)  A focused assessment/specific body system 
B)  The Resident Assessment Instrument/Minimum Data Set 
C)  An admission assessment and acuity level 
D)  An intake assessment form and auditing phase

Question 3

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

Question 4

A nurse is teaching the staff about health care reimbursement.Which information should the nurse include?

Accepted Answer

A)  Sentinel events help determine reimbursement issues for health care. 
B)  Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. 
C)  A clinical information system must be installed by 2014 to obtain health care reimbursement. 
D)  HIPAA is the basis for establishing reimbursement for health care. 
A)  Sentinel events help determine reimbursement issues for health care. 
B)  Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. 
C)  A clinical information system must be installed by 2014 to obtain health care reimbursement. 
D)  HIPAA is the basis for establishing reimbursement for health care.

Question 5

A nurse prepared an audiotaped exchange with another nurse of information about a patient.Which action did the nurse complete? The nurse completed a

Accepted Answer

A)  Report. 
B)  Record. 
C)  Consultation. 
D)  Referral. 
A)  Report. 
B)  Record. 
C)  Consultation. 
D)  Referral.

Question 6

Which situation will require the nurse to obtain a telephone order?

Accepted Answer

A)  As the nurse and primary care provider leave a patient's room, the primary care provider gives the nurse an order. 
B)  At 0100, a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood. 
C)  At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order. 
D)  A nurse reads an order correctly as written by the primary care provider in the patient's medical record. 
A)  As the nurse and primary care provider leave a patient's room, the primary care provider gives the nurse an order. 
B)  At 0100, a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood. 
C)  At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order. 
D)  A nurse reads an order correctly as written by the primary care provider in the patient's medical record.

Question 7

Identify the purposes of a health care record.

Accepted Answer

A)  Communication 
B)  Legal documentation 
C)  Reimbursement 
D)  Education 
E)  Research
F) Nursing process 
A)  Communication 
B)  Legal documentation 
C)  Reimbursement 
D)  Education 
E)  Research
F) Nursing process

Question 8

A nurse has taught the staff about informatics.Which statement indicates that the staff needs more education?

Accepted Answer

A)  If a nurse has computer competency, the nurse is competent in informatics. 
B)  To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice. 
C)  A nurse needs to know how to acquire, critique, and apply scientific evidence from literature databases. 
D)  Nursing informatics integrates nursing science, computer science, and information science to manage and communicate information in nursing practice. 
A)  If a nurse has computer competency, the nurse is competent in informatics. 
B)  To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice. 
C)  A nurse needs to know how to acquire, critique, and apply scientific evidence from literature databases. 
D)  Nursing informatics integrates nursing science, computer science, and information science to manage and communicate information in nursing practice.

Question 9

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

Accepted Answer

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

Question 10

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart.What is the preceptor's best response?

Accepted Answer

A)  "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care." 
B)  "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs." 
C)  "A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities." 
D)  "A change-of-shift report provides important information to caregivers and develops relationships within the health care team." 
A)  "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care." 
B)  "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs." 
C)  "A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities." 
D)  "A change-of-shift report provides important information to caregivers and develops relationships within the health care team."

Question 11

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records?

Accepted Answer

A)  The nurse determines the degree to which standards of care are met by reviewing patients' health records. 
B)  The nurse realizes that care not documented in patients' health records still qualifies as care provided. 
C)  The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. 
D)  The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment. 
A)  The nurse determines the degree to which standards of care are met by reviewing patients' health records. 
B)  The nurse realizes that care not documented in patients' health records still qualifies as care provided. 
C)  The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. 
D)  The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment.

Exam 26: Documentation and Informatics

Which behaviors indicate that the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)?

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement within and across facilities.Which task did the nurse just complete?

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 is teaching the staff about health care reimbursement.Which information should the nurse include?

A nurse prepared an audiotaped exchange with another nurse of information about a patient.Which action did the nurse complete? The nurse completed a

Which situation will require the nurse to obtain a telephone order?

Identify the purposes of a health care record.

A nurse has taught the staff about informatics.Which statement indicates that the staff needs more education?

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

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart.What is the preceptor's best response?

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records?

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