Exam 3: Documentation and Informatics

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

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?

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.Why would the nurse initiate an incident report?

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

At 9:15 AM the nurse repeatedly instructs the patient to remain in bed.At 9:30 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?

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

The nursing staff is 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 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?

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?

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 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."

The nursing staff has 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 documents patient care using the SOAP format.Which should the nurse record under the "P" section?

The nursing staff is using a worksheet that contains information for change-of-shift report and facilitates access to information when referring to the patient's computerized record.Which document is the nursing staff using?

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 "PIE" format is used on the nursing unit.Which entry should the nurse place in the "E" part of the format?

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

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