Question 1

Which statement exemplifies important patient information in the change-of-shift report?

Accepted Answer

A)  The patient sent his dinner tray back to the kitchen twice because the food was cold. 
B)  The patient keeps taking his nasal cannula off and threading it around the side rails of the bed. 
C)  The patient prefers to drink coffee that has cooled to room temperature with two sugars and two creamers. 
D)  The patient took all of the prescribed morning medications with a big glass of apple juice. 
A)  The patient sent his dinner tray back to the kitchen twice because the food was cold. 
B)  The patient keeps taking his nasal cannula off and threading it around the side rails of the bed. 
C)  The patient prefers to drink coffee that has cooled to room temperature with two sugars and two creamers. 
D)  The patient took all of the prescribed morning medications with a big glass of apple juice.

Question 2

Which chart entry represents appropriate documentation about the patient's pain assessment?

Accepted Answer

A)  The patient appears not to be in any pain. 
B)  The patient is sleeping comfortably. 
C)  The patient always complains about being in pain. 
D)  The patient rated the pain at 2 on a 0-to-10 scale. 
A)  The patient appears not to be in any pain. 
B)  The patient is sleeping comfortably. 
C)  The patient always complains about being in pain. 
D)  The patient rated the pain at 2 on a 0-to-10 scale.

Question 3

Before leaving at the end of the shift,the nurse realizes that a set of patient assessments were taken earlier in the day but never charted.What is the appropriate action of the nurse?

Accepted Answer

A)  Enter the assessments in the chart the next day before receiving report. 
B)  Do nothing because the other patient assessments were obtained during the shift. 
C)  Direct the nursing assistant to enter the assessments into the patient's chart. 
D)  Enter the assessments into the chart as a late entry with a reason for the delay. 
A)  Enter the assessments in the chart the next day before receiving report. 
B)  Do nothing because the other patient assessments were obtained during the shift. 
C)  Direct the nursing assistant to enter the assessments into the patient's chart. 
D)  Enter the assessments into the chart as a late entry with a reason for the delay.

Question 4

The nurse is working at a hospital whose electronic medical records system uses charting by exception.Which entry would be appropriate to include in the narrative section of the patient's chart?

Accepted Answer

A)  The patient voided 400 mL of clear yellow urine during the last 12 hours. 
B)  The patient denies smoking,alcohol intake,or use of illicit substances. 
C)  The patient states that the pain level in his right knee is 7 on a 1-to-10 scale. 
D)  The patient's lung sounds are clear bilaterally with no cyanosis or dyspnea. 
A)  The patient voided 400 mL of clear yellow urine during the last 12 hours. 
B)  The patient denies smoking,alcohol intake,or use of illicit substances. 
C)  The patient states that the pain level in his right knee is 7 on a 1-to-10 scale. 
D)  The patient's lung sounds are clear bilaterally with no cyanosis or dyspnea.

Question 5

What is the best method for to The Joint Commission to demonstrate that it is assessing quality patient care?

Accepted Answer

A)  Cost of care per patient day 
B)  Number of registered nurses 
C)  Absence of sentinel events 
D)  Documentation audits 
A)  Cost of care per patient day 
B)  Number of registered nurses 
C)  Absence of sentinel events 
D)  Documentation audits

Question 6

The nurse is caring for a patient who climbed out of bed and fell on the floor.What will the nurse do in regard to the incident report?

Accepted Answer

A)  Document how the patient was found and a description of the injuries. 
B)  Include recommendations for future fall prevention interventions. 
C)  Note in the patient's chart that an incident report was completed. 
D)  Indicate that the nursing assistant wasn't doing her job correctly. 
E)  Document fall prevention steps that were in place before the patient fell. 
A)  Document how the patient was found and a description of the injuries. 
B)  Include recommendations for future fall prevention interventions. 
C)  Note in the patient's chart that an incident report was completed. 
D)  Indicate that the nursing assistant wasn't doing her job correctly. 
E)  Document fall prevention steps that were in place before the patient fell.

Question 7

Which information must be included in the patient's discharge summary?

Accepted Answer

A)  The patient is to follow up with the primary care physician in 14 days. 
B)  The patient arrived at the hospital by ambulance with acute shortness of breath. 
C)  Supplemental oxygen was administered to the patient in the emergency room. 
D)  The patient is to have a protime (PT)level drawn daily for the next 7 days. 
E)  The patient is to take the prescribed antibiotic daily even after symptoms subside 
A)  The patient is to follow up with the primary care physician in 14 days. 
B)  The patient arrived at the hospital by ambulance with acute shortness of breath. 
C)  Supplemental oxygen was administered to the patient in the emergency room. 
D)  The patient is to have a protime (PT)level drawn daily for the next 7 days. 
E)  The patient is to take the prescribed antibiotic daily even after symptoms subside

Question 8

The nurse realizes that the wrong patient's name was written on several important paperwork forms that were already signed by the attending physician.How will the nurse correct this error?

Accepted Answer

A)  Black out the error with a thick marker and enter the correct information. 
B)  Use correction tape to write over the incorrect information. 
C)  Draw one line through the error,make the correction and initial it. 
D)  Shred the forms with the incorrect information and write on new ones. 
A)  Black out the error with a thick marker and enter the correct information. 
B)  Use correction tape to write over the incorrect information. 
C)  Draw one line through the error,make the correction and initial it. 
D)  Shred the forms with the incorrect information and write on new ones.

Question 9

Which statement by the nurse accurately reflects a benefit of installing a new electronic medical record system?

Accepted Answer

A)  "I am thankful that I won't have to keep changing my passwords all the time." 
B)  "I'll be able to see my son's medical record using my password and user ID." 
C)  "I won't have to worry about reading the doctor's messy handwriting anymore." 
D)  "It will take me so much less time than writing everything out on paper." 
A)  "I am thankful that I won't have to keep changing my passwords all the time." 
B)  "I'll be able to see my son's medical record using my password and user ID." 
C)  "I won't have to worry about reading the doctor's messy handwriting anymore." 
D)  "It will take me so much less time than writing everything out on paper."

Question 10

Which patient situations require the completion of an incident report?

Accepted Answer

A)  A patient almost receives the wrong medication due to unclear wording on the packaging from the pharmacy. 
B)  A patient repeatedly refuses to eat food from the hospital kitchen because it is always too salty or too cold. 
C)  A visitor trips on an icy sidewalk in the hospital parking lot and suffers a fractured wrist. 
D)  The nurse accidentally enters the wrong vital signs into the patient's medical record and corrects the error shortly afterward. 
E)  The patient dislikes male nursing staff and prefers to have only female nurses providing personal care. 
A)  A patient almost receives the wrong medication due to unclear wording on the packaging from the pharmacy. 
B)  A patient repeatedly refuses to eat food from the hospital kitchen because it is always too salty or too cold. 
C)  A visitor trips on an icy sidewalk in the hospital parking lot and suffers a fractured wrist. 
D)  The nurse accidentally enters the wrong vital signs into the patient's medical record and corrects the error shortly afterward. 
E)  The patient dislikes male nursing staff and prefers to have only female nurses providing personal care.

Exam 10: Informatics and Documentation

Which statement exemplifies important patient information in the change-of-shift report?

Which chart entry represents appropriate documentation about the patient's pain assessment?

Before leaving at the end of the shift,the nurse realizes that a set of patient assessments were taken earlier in the day but never charted.What is the appropriate action of the nurse?

The nurse is working at a hospital whose electronic medical records system uses charting by exception.Which entry would be appropriate to include in the narrative section of the patient's chart?

What is the best method for to The Joint Commission to demonstrate that it is assessing quality patient care?

The nurse is caring for a patient who climbed out of bed and fell on the floor.What will the nurse do in regard to the incident report?

Which information must be included in the patient's discharge summary?

The nurse realizes that the wrong patient's name was written on several important paperwork forms that were already signed by the attending physician.How will the nurse correct this error?

Which statement by the nurse accurately reflects a benefit of installing a new electronic medical record system?

Which patient situations require the completion of an incident report?

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

Surgical Patient

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