Question 1

Which statement(s)by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply.

Accepted Answer

A)  "I can wait until the end of the shift to document my care." 
B)  "Charting every 2 hours is the most appropriate way to document nursing care." 
C)  "I find it easier to chart before I go to lunch, and then after my shift report." 
D)  "I should chart as soon as possible after nursing care is given." 
A)  "I can wait until the end of the shift to document my care." 
B)  "Charting every 2 hours is the most appropriate way to document nursing care." 
C)  "I find it easier to chart before I go to lunch, and then after my shift report." 
D)  "I should chart as soon as possible after nursing care is given."

Question 2

The department of nursing at a local hospital is considering changing to charting by exception (CBE).A major disadvantage of CBE is that it:

Accepted Answer

A)  Increases the time nurses spend on charting in narrative format 
B)  Does not clearly identify deviations from normal expectations 
C)  Requires all providers to document in the same sections of the chart 
D)  Can increase the risk of omissions in patient care 
A)  Increases the time nurses spend on charting in narrative format 
B)  Does not clearly identify deviations from normal expectations 
C)  Requires all providers to document in the same sections of the chart 
D)  Can increase the risk of omissions in patient care

Question 3

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident is of a long-term care facility?

Accepted Answer

A)  14 days 
B)  3 days 
C)  2 days 
D)  24 hours 
A)  14 days 
B)  3 days 
C)  2 days 
D)  24 hours

Question 4

A medical provider has prescribed milk of magnesia (magnesium hydroxide)30 mL,PO bid.Here bid means :

Accepted Answer

A)  Once every day 
B)  Two times every day 
C)  Three times every day 
D)  Four times a day 
A)  Once every day 
B)  Two times every day 
C)  Three times every day 
D)  Four times a day

Question 5

Which of the following is the most beneficial aspect of electronic documentation systems?

Accepted Answer

A)  Assist collaboration 
B)  Provide cautionary reminders 
C)  Improve legibility 
D)  Serve as a resource 
A)  Assist collaboration 
B)  Provide cautionary reminders 
C)  Improve legibility 
D)  Serve as a resource

Question 6

Which action by the nurse breaches patient confidentiality? Select all that apply.

Accepted Answer

A)  Leaving patient data displayed on a computer screen where others may view it 
B)  Remaining logged on to the computer system after documenting patient care 
C)  Faxing a patient report to the nurses' station where the patient is being transferred 
D)  Informing the nurse manager of a change in the patient's condition 
A)  Leaving patient data displayed on a computer screen where others may view it 
B)  Remaining logged on to the computer system after documenting patient care 
C)  Faxing a patient report to the nurses' station where the patient is being transferred 
D)  Informing the nurse manager of a change in the patient's condition

Question 7

Which set of topics makes up a handoff report given in a recommended format?

Accepted Answer

A)  Data-action-response (DAR) 
B)  Subjective-objective-assessment-plan (SOAP) 
C)  Situation-background-assessment-recommendation (SBAR) 
D)  Patient-diagnosis-medications-activity 
A)  Data-action-response (DAR) 
B)  Subjective-objective-assessment-plan (SOAP) 
C)  Situation-background-assessment-recommendation (SBAR) 
D)  Patient-diagnosis-medications-activity

Question 8

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery,a colon resection,for colon cancer.Which integrated plan of care (IPOC)would be most appropriate for the nurse to implement?

Accepted Answer

A)  Hypertension 
B)  Rheumatoid arthritis 
C)  Postoperative colon resection 
D)  Follow all three plans 
A)  Hypertension 
B)  Rheumatoid arthritis 
C)  Postoperative colon resection 
D)  Follow all three plans

Question 9

Which prescription below is not consistent with the standards established by The Joint Commission?

Accepted Answer

A)  Administer Lasix 20 mg PO daily at 1000. 
B)  Administer Lasix 10.0 mg PO daily at 1000. 
C)  Administer digoxin 10 mg PO daily at 1000. 
D)  Administer digoxin 0.3 mg IV daily at 1000. 
A)  Administer Lasix 20 mg PO daily at 1000. 
B)  Administer Lasix 10.0 mg PO daily at 1000. 
C)  Administer digoxin 10 mg PO daily at 1000. 
D)  Administer digoxin 0.3 mg IV daily at 1000.

Question 10

A hospital uses a source-oriented medical record.What is a major disadvantage of this charting system?

Accepted Answer

A)  It involves a cooperative effort among various disciplines. 
B)  The system requires diligence in maintaining a current problem list. 
C)  Data may be fragmented and scattered throughout the chart. 
D)  It allows the nurse to provide information in an unorganized manner. 
A)  It involves a cooperative effort among various disciplines. 
B)  The system requires diligence in maintaining a current problem list. 
C)  Data may be fragmented and scattered throughout the chart. 
D)  It allows the nurse to provide information in an unorganized manner.

Question 11

At 1000 on 11/14/16,the nurse takes a telephone prescription for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order?

Accepted Answer

A)  11/14/16 at 1200 
B)  11/14/16 at 2200 
C)  11/15/16 at 1000 
D)  11/16/16 at 1000 
A)  11/14/16 at 1200 
B)  11/14/16 at 2200 
C)  11/15/16 at 1000 
D)  11/16/16 at 1000

Question 12

The nursing assistive personnel (NAP)informs the nurse that a patient has fallen out of bed and is in pain.The nurse assesses the patient and provides care.Identify the correct documentation of the fall.

Accepted Answer

A)  Patient found on floor after falling out of bed and verbalizes (L) hip pain. 
B)  Patient found on floor by NAP Smith and verbalizing (L) hip pain. 
C)  Patient fell out of bed but is currently in bed. 
D)  Patient reminded not to climb OOB after falling. 
A)  Patient found on floor after falling out of bed and verbalizes (L) hip pain. 
B)  Patient found on floor by NAP Smith and verbalizing (L) hip pain. 
C)  Patient fell out of bed but is currently in bed. 
D)  Patient reminded not to climb OOB after falling.

Question 13

The implementation of electronic health records (EHRs)allows the nurse to do which of the following? Select all that apply.

Accepted Answer

A)  Use trend data to facilitate evidence-based nursing practice 
B)  Promote efficient use of time spent charting 
C)  Reduce the opportunity for interdisciplinary collaboration 
D)  Activate the system's safeguards to promote client safety 
A)  Use trend data to facilitate evidence-based nursing practice 
B)  Promote efficient use of time spent charting 
C)  Reduce the opportunity for interdisciplinary collaboration 
D)  Activate the system's safeguards to promote client safety

Exam 18: Documenting Reporting

Which statement(s)by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply.

The department of nursing at a local hospital is considering changing to charting by exception (CBE).A major disadvantage of CBE is that it:

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident is of a long-term care facility?

A medical provider has prescribed milk of magnesia (magnesium hydroxide)30 mL,PO bid.Here bid means :

Which of the following is the most beneficial aspect of electronic documentation systems?

Which action by the nurse breaches patient confidentiality? Select all that apply.

Which set of topics makes up a handoff report given in a recommended format?

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery,a colon resection,for colon cancer.Which integrated plan of care (IPOC)would be most appropriate for the nurse to implement?

Which prescription below is not consistent with the standards established by The Joint Commission?

A hospital uses a source-oriented medical record.What is a major disadvantage of this charting system?

At 1000 on 11/14/16,the nurse takes a telephone prescription for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order?

The nursing assistive personnel (NAP)informs the nurse that a patient has fallen out of bed and is in pain.The nurse assesses the patient and provides care.Identify the correct documentation of the fall.

The implementation of electronic health records (EHRs)allows the nurse to do which of the following? Select all that apply.

Evolution of Nursing Thought Action

Critical Thinking: Nursing Process

Nursing Process: Assessment

Nursing Process: Diagnosis

Nursing Process: Planning Outcomes

Nursing Process: Planning Interventions

Nursing Process: Implementation Evaluation

Evidence-Based Practice: Theory Research

Life Span: Infancy Through Middle Adulthood

Life Span: Older Adults

Experiencing Health Illness

Stress Adaptation

Psychosocial Health Illness

The Family

Culture Ethnicity

Spirituality

Loss,Grief, Dying

Teaching Learning

Measuring Vital Signs

Communication Therapeutic Relationships

Health Assessment

Promoting Asepsis Preventing Infection

Promoting Safety

Facilitating Hygiene

Administering Medications

Nutrition

Urinary Elimination

Bowel Elimination

Sensation,Perception, Cognition

Pain

Physical Activity Mobility

Sexual Health

Sleep and Rest

Skin Integrity-Wound Healing

Oxygenation

Circulation

Fluids,Electrolytes, Acidbase Balance

Perioperative Care

Leading Managing

Nursing Informatics

Promoting Health

Community-Home Health Nursing

Ethics Values

Legal Accountability

Holistic Healing

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