Question 1

A nurse completes an incident/occurrence report after a patient fell.What is the reason for this report?

Accepted Answer

A)  To compare patient fall rates between nursing units in the hospital 
B)  To provide justification for the hospital to fire the nurse 
C)  To prevent the patient from filing a malpractice lawsuit 
D)  To aid in the hospital's quality improvement program 
A)  To compare patient fall rates between nursing units in the hospital 
B)  To provide justification for the hospital to fire the nurse 
C)  To prevent the patient from filing a malpractice lawsuit 
D)  To aid in the hospital's quality improvement program D

Question 2

Which entry in the patient's chart will justify home nursing care reimbursement from Medicare,Medicaid,and private insurance companies?

Accepted Answer

A)  The patient's wound is improving slightly each day. 
B)  The patient was receptive to the smoking cessation information. 
C)  The patient's family appreciated the nurse's caring demeanor. 
D)  The patient's wound was 6 cm × 4 cm and is now 4 cm × 2 cm. 
A)  The patient's wound is improving slightly each day. 
B)  The patient was receptive to the smoking cessation information. 
C)  The patient's family appreciated the nurse's caring demeanor. 
D)  The patient's wound was 6 cm × 4 cm and is now 4 cm × 2 cm. D

Question 3

The patient requests that her chart be destroyed as soon as she is discharged.What is the best response of the nurse?

Accepted Answer

A)  "The hospital can give you the chart after you are discharged." 
B)  "Your chart will be kept secure and confidential." 
C)  "The information must be reported to the health department first." 
D)  "Your chart can be shredded if you give consent." 
A)  "The hospital can give you the chart after you are discharged." 
B)  "Your chart will be kept secure and confidential." 
C)  "The information must be reported to the health department first." 
D)  "Your chart can be shredded if you give consent." B

Question 4

Which is the correct military time entry for a medication that was administered at 8:30 p.m.?

Accepted Answer

A)  0830 
B)  140 
C)  2030 
D)  2230 
A)  0830 
B)  140 
C)  2030 
D)  2230

Question 5

The patient developed a large hematoma where the laboratory technician drew blood earlier in the shift.Which statement is appropriate to enter in the patient's chart?

Accepted Answer

A)  The laboratory technician did not know what he was doing and traumatized the patient's arm. 
B)  The patient has a painful raised 2-inch × 2-inch hematoma on the outer left arm after venipuncture. 
C)  The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised. 
D)  The patient must have moved during the blood draw because there is a huge bruise on his left arm. 
A)  The laboratory technician did not know what he was doing and traumatized the patient's arm. 
B)  The patient has a painful raised 2-inch × 2-inch hematoma on the outer left arm after venipuncture. 
C)  The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised. 
D)  The patient must have moved during the blood draw because there is a huge bruise on his left arm.

Question 6

The patient's daughter requests to see the patient's medical record.What is the nurse's appropriate response?

Accepted Answer

A)  "Come with me and we will look at it together." 
B)  "I'm sorry but that information is confidential." 
C)  "Let me ask my supervisor if it is okay." 
D)  "The doctor will have to give permission first." 
A)  "Come with me and we will look at it together." 
B)  "I'm sorry but that information is confidential." 
C)  "Let me ask my supervisor if it is okay." 
D)  "The doctor will have to give permission first."

Question 7

Which specifics of care will be included in a patient's critical pathway?

Accepted Answer

A)  Refer the patient to the outpatient cardiac rehabilitation program. 
B)  Elevate the head of the patient's bed to ease shortness of breath. 
C)  Provide small meals throughout the day and encourage fluid intake. 
D)  Teach the patient how to use relaxation techniques to ease shortness of breath. 
A)  Refer the patient to the outpatient cardiac rehabilitation program. 
B)  Elevate the head of the patient's bed to ease shortness of breath. 
C)  Provide small meals throughout the day and encourage fluid intake. 
D)  Teach the patient how to use relaxation techniques to ease shortness of breath.

Question 8

Which agency creates standards that require nursing documentation to be accurate,timely,and patient-centered?

Accepted Answer

A)  Centers for Disease Control and Prevention 
B)  World Health Organization 
C)  The Joint Commission 
D)  Agency for Healthcare Research and Quality 
A)  Centers for Disease Control and Prevention 
B)  World Health Organization 
C)  The Joint Commission 
D)  Agency for Healthcare Research and Quality

Question 9

Which chart entry reflects appropriate documentation of patient data?

Accepted Answer

A)  The patient voided a moderate amount of urine. 
B)  The patient voided 220 mL of clear yellow urine. 
C)  The patient was incontinent. 
D)  The patient voided an adequate amount of urine for the shift. 
A)  The patient voided a moderate amount of urine. 
B)  The patient voided 220 mL of clear yellow urine. 
C)  The patient was incontinent. 
D)  The patient voided an adequate amount of urine for the shift.

Question 10

Which action by the nurse minimizes the risk of unauthorized use of computer passwords for the electronic medical record system?

Accepted Answer

A)  Using the same password for home and health care agency computers 
B)  Writing each new computer password on the back of the name badge 
C)  Periodically reusing previous computer passwords to prevent forgetting them 
D)  Using passwords of at least eight characters with at least one number and symbol 
A)  Using the same password for home and health care agency computers 
B)  Writing each new computer password on the back of the name badge 
C)  Periodically reusing previous computer passwords to prevent forgetting them 
D)  Using passwords of at least eight characters with at least one number and symbol

Question 11

Which patient information may be included in the nursing student's assignment that will be turned in to the instructor after the clinical shift has ended?

Accepted Answer

A)  Room number 
B)  Date of birth 
C)  Medical record number 
D)  Nursing diagnosis 
A)  Room number 
B)  Date of birth 
C)  Medical record number 
D)  Nursing diagnosis

Question 12

Which is the primary purpose of a patient's medical record?

Accepted Answer

A)  To invoice the nursing services for hospital reimbursement 
B)  To protect the patient in case of a malpractice suit 
C)  To facilitate professional communication and safe health care 
D)  To contribute to a worldwide databank for trends in health care 
A)  To invoice the nursing services for hospital reimbursement 
B)  To protect the patient in case of a malpractice suit 
C)  To facilitate professional communication and safe health care 
D)  To contribute to a worldwide databank for trends in health care

Question 13

The nurse has just completed teaching the patient how to self-administer insulin injections.Which entry in the patient's chart demonstrates that the teaching was successful?

Accepted Answer

A)  The patient correctly self-administered his next scheduled dose of insulin. 
B)  The patient denied having any questions or concerns about the procedure. 
C)  Additional written instructions about how to perform the injection was provided. 
D)  The patient identified the steps and equipment used for the injection. 
A)  The patient correctly self-administered his next scheduled dose of insulin. 
B)  The patient denied having any questions or concerns about the procedure. 
C)  Additional written instructions about how to perform the injection was provided. 
D)  The patient identified the steps and equipment used for the injection.

Question 14

The nurse is entering a note in the patient's medical record using the SOAP format.Which statement belongs in the Assessment section?

Accepted Answer

A)  The patient stated "I started feeling short of breath after smelling strong perfume." 
B)  The patient is using accessory muscles and has wheezes in all lung fields. 
C)  Ineffective airway clearance related to exposure to environmental allergen. 
D)  Monitor pulse oximetry and administer nebulized bronchodilators. 
A)  The patient stated "I started feeling short of breath after smelling strong perfume." 
B)  The patient is using accessory muscles and has wheezes in all lung fields. 
C)  Ineffective airway clearance related to exposure to environmental allergen. 
D)  Monitor pulse oximetry and administer nebulized bronchodilators.

Question 15

At the nursing station,the nurse receives a verbal order from the physician for a routine medication.What is the best action of the nurse?

Accepted Answer

A)  Request that the doctor enter the order into the computer. 
B)  Repeat the order to the doctor and enter it into the computer. 
C)  Direct the unit secretary to enter the order into the computer. 
D)  Call the pharmacy to determine that the drug dosage is appropriate. 
A)  Request that the doctor enter the order into the computer. 
B)  Repeat the order to the doctor and enter it into the computer. 
C)  Direct the unit secretary to enter the order into the computer. 
D)  Call the pharmacy to determine that the drug dosage is appropriate.

Question 16

What is the priority action of the nurse immediately after receiving a medication telephone order from a physician?

Accepted Answer

A)  Withhold the medication until the physician signs the order. 
B)  Authorize the physician's order with the pharmacy. 
C)  Read back the order to the physician for confirmation. 
D)  Double-check the order with another registered nurse. 
A)  Withhold the medication until the physician signs the order. 
B)  Authorize the physician's order with the pharmacy. 
C)  Read back the order to the physician for confirmation. 
D)  Double-check the order with another registered nurse.

Question 17

The patient was not able to continue along the migraine headache critical pathway after suffering a stroke.Which terminology describes this deviation from the prescribed pathway?

Accepted Answer

A)  Negative variance 
B)  Noncompliance with the treatment plan 
C)  Risk-prone health behavior 
D)  Care plan intolerance 
A)  Negative variance 
B)  Noncompliance with the treatment plan 
C)  Risk-prone health behavior 
D)  Care plan intolerance

Question 18

Which information must be shared during the hand-off report to the oncoming nurse?

Accepted Answer

A)  The patient is nauseated and complaining of moderate generalized pain. 
B)  The patient has six children and fourteen grandchildren. 
C)  The patient will drink chicken broth but prefers to have lime gelatin. 
D)  The patient sent back the dinner tray twice because the food was cold. 
A)  The patient is nauseated and complaining of moderate generalized pain. 
B)  The patient has six children and fourteen grandchildren. 
C)  The patient will drink chicken broth but prefers to have lime gelatin. 
D)  The patient sent back the dinner tray twice because the food was cold.

Question 19

The nurse fills out an incident report after a patient fall but makes no mention of the report in the patient's medical record.What is the reason for this?

Accepted Answer

A)  The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report. 
B)  The incident report includes the nurse's interpretations of what probably led the patient to get out of bed. 
C)  A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall. 
D)  The incident report is confidential and not intended to be used as evidence in a malpractice suit. 
A)  The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report. 
B)  The incident report includes the nurse's interpretations of what probably led the patient to get out of bed. 
C)  A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall. 
D)  The incident report is confidential and not intended to be used as evidence in a malpractice suit.

Question 20

After a patient fall,the supervisor asks the nurse to rewrite the entry in the patient's chart to show that the patient's bed was lowered to the floor even though it was not.What is the best action of the nurse?

Accepted Answer

A)  Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. 
B)  Remind the supervisor that it is against regulations to alter or falsify the patient's chart. 
C)  Ask the nurse assistant to chart that the patient's bed was lowered to the floor at the time of the fall. 
D)  Rewrite the entry as requested but note that the patient's bed was not lowered to the floor in the incident report. 
A)  Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. 
B)  Remind the supervisor that it is against regulations to alter or falsify the patient's chart. 
C)  Ask the nurse assistant to chart that the patient's bed was lowered to the floor at the time of the fall. 
D)  Rewrite the entry as requested but note that the patient's bed was not lowered to the floor in the incident report.

Exam 10: Informatics and Documentation

A nurse completes an incident/occurrence report after a patient fell.What is the reason for this report?

Which entry in the patient's chart will justify home nursing care reimbursement from Medicare,Medicaid,and private insurance companies?

The patient requests that her chart be destroyed as soon as she is discharged.What is the best response of the nurse?

Which is the correct military time entry for a medication that was administered at 8:30 p.m.?

The patient developed a large hematoma where the laboratory technician drew blood earlier in the shift.Which statement is appropriate to enter in the patient's chart?

The patient's daughter requests to see the patient's medical record.What is the nurse's appropriate response?

Which specifics of care will be included in a patient's critical pathway?

Which agency creates standards that require nursing documentation to be accurate,timely,and patient-centered?

Which chart entry reflects appropriate documentation of patient data?

Which action by the nurse minimizes the risk of unauthorized use of computer passwords for the electronic medical record system?

Which patient information may be included in the nursing student's assignment that will be turned in to the instructor after the clinical shift has ended?

Which is the primary purpose of a patient's medical record?

The nurse has just completed teaching the patient how to self-administer insulin injections.Which entry in the patient's chart demonstrates that the teaching was successful?

The nurse is entering a note in the patient's medical record using the SOAP format.Which statement belongs in the Assessment section?

At the nursing station,the nurse receives a verbal order from the physician for a routine medication.What is the best action of the nurse?

What is the priority action of the nurse immediately after receiving a medication telephone order from a physician?

The patient was not able to continue along the migraine headache critical pathway after suffering a stroke.Which terminology describes this deviation from the prescribed pathway?

Which information must be shared during the hand-off report to the oncoming nurse?

The nurse fills out an incident report after a patient fall but makes no mention of the report in the patient's medical record.What is the reason for this?

After a patient fall,the supervisor asks the nurse to rewrite the entry in the patient's chart to show that the patient's bed was lowered to the floor even though it was not.What is the best action of the nurse?

Professional Nursing

Health and Wellness

The Health Care Delivery System

Community-Based Nursing Practice

Legal Principles in Nursing

Ethics

Evidence-Based Practice

Critical Thinking

Nursing Process

Communication

Patient Education

Managing Patient Care

Infection Prevention and Control

Vital Signs

Health Assessment and Physical Examination

Administering Medications

Fluid, Electrolyte, and Acid-Base Balances

Complementary and Alternative Therapies

Caring in Nursing Practice

Cultural Awareness

Spiritual Health

Growth and Development

Self-Concept and Sexuality

Family Dynamics

Stress and Coping

Loss and Grief

Exercise and Activity

Immobility

Safety

Hygiene

Oxygenation

Sleep

Pain Management

Nutrition

Urinary Elimination

Bowel Elimination

Skin Integrity and Wound Care

Sensory Alterations

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