Question 1

A nurse is using critical pathways to care for a patient.Which area will the nurse address according to the pathway?

Accepted Answer

A)  Activity 
B)  Nursing diagnosis 
C)  Times to chart 
D)  Admission form 
A)  Activity 
B)  Nursing diagnosis 
C)  Times to chart 
D)  Admission form A

Question 2

Which documentation by the nurse best describes patient data?

Accepted Answer

A)  "Moderate amount of clear yellow urine voided." 
B)  "Voided 220 mL clear yellow urine." 
C)  "A small amount of urine voided into absorbent pad." 
D)  "Patient incontinent of urine." 
A)  "Moderate amount of clear yellow urine voided." 
B)  "Voided 220 mL clear yellow urine." 
C)  "A small amount of urine voided into absorbent pad." 
D)  "Patient incontinent of urine." B

Question 3

A new registered nurse is working on a pediatric unit in a large teaching hospital that uses focus charting with the acronym DAR.What will the nurse be charting?

Accepted Answer

A)  Data, assessment, reaction 
B)  Data, assessment, recommendation 
C)  Data, actions, response 
D)  Data, actions, recovery 
A)  Data, assessment, reaction 
B)  Data, assessment, recommendation 
C)  Data, actions, response 
D)  Data, actions, recovery C

Question 4

A registered nurse recently changed jobs and is now working in home health.What must the nurse chart to obtain reimbursement from Medicare,Medicaid,and private insurance companies?

Accepted Answer

A)  Patient's response to care 
B)  Whether patient had a good or bad day 
C)  Whether family liked nurse or not 
D)  Patient's number of marriages 
A)  Patient's response to care 
B)  Whether patient had a good or bad day 
C)  Whether family liked nurse or not 
D)  Patient's number of marriages

Question 5

A nurse is using SBAR and tells the primary health care provider that the abdomen is distended and firm with a pain rating of 8 on a 0-10 scale.Which component of SBAR did the nurse communicate?

Accepted Answer

A)  S 
B)  B 
C)  A 
D)  R 
A)  S 
B)  B 
C)  A 
D)  R

Question 6

A nurse began working at a local hospital and learned that the hospital had just instituted a "hand-off" protocol.What will the nurse be doing?

Accepted Answer

A)  Performing transfer reports 
B)  Completing IV fluid flow sheets 
C)  Using standardized care plans 
D)  Reviewing laboratory reports 
A)  Performing transfer reports 
B)  Completing IV fluid flow sheets 
C)  Using standardized care plans 
D)  Reviewing laboratory reports

Question 7

Which information indicates the nurse has a correct understanding of the purpose of a patient's medical record?

Accepted Answer

A)  To invoice the nurse for reimbursement 
B)  To protect the patient in case of a malpractice suit 
C)  To ensure everyone is working toward a common goal of providing safe care 
D)  To contribute to a worldwide databank for trends in health care 
A)  To invoice the nurse for reimbursement 
B)  To protect the patient in case of a malpractice suit 
C)  To ensure everyone is working toward a common goal of providing safe care 
D)  To contribute to a worldwide databank for trends in health care

Question 8

A nurse completes an incident/occurrence report on a patient who fell while walking in the hallway.The nurse completes this report for what purpose?

Accepted Answer

A)  To exchange information among health care members 
B)  To provide information about patients on one unit to another 
C)  To prevent a legal lawsuit from the patient 
D)  To aid in the hospital's quality improvement program 
A)  To exchange information among health care members 
B)  To provide information about patients on one unit to another 
C)  To prevent a legal lawsuit from the patient 
D)  To aid in the hospital's quality improvement program

Question 9

A nurse is preparing a discharge summary.Which item should the nurse include?

Accepted Answer

A)  Provision for follow-up care 
B)  Patient status at admission 
C)  Standardized nursing care plan 
D)  Detailed description of nursing procedures 
A)  Provision for follow-up care 
B)  Patient status at admission 
C)  Standardized nursing care plan 
D)  Detailed description of nursing procedures

Question 10

A nurse is teaching the staff about informatics and describing the key concepts.Which information should the nurse include during the teaching session?

Accepted Answer

A)  Wisdom 
B)  Charting 
C)  Assessment 
D)  Evaluation 
A)  Wisdom 
B)  Charting 
C)  Assessment 
D)  Evaluation

Question 11

A nurse is documenting the last entry for the day.It is 3:15 PM and the agency uses military time.Which time should the nurse enter?

Accepted Answer

A)  315 
B)  0315 
C)  1315 
D)  1515 
A)  315 
B)  0315 
C)  1315 
D)  1515

Question 12

Which guidelines must the nurse follow to appropriately manage electronic patient information? (Select all that apply.)

Accepted Answer

A)  Never share passwords with co-workers. 
B)  Only the supervisor should have the nurse's password and it should be stored in a protected place. 
C)  Leave the computer terminal unattended when logged on. 
D)  Avoid leaving patient information displayed on a computer where others can see it. 
E)  Keep the same password for as long as the nurse works at the agency. 
A)  Never share passwords with co-workers. 
B)  Only the supervisor should have the nurse's password and it should be stored in a protected place. 
C)  Leave the computer terminal unattended when logged on. 
D)  Avoid leaving patient information displayed on a computer where others can see it. 
E)  Keep the same password for as long as the nurse works at the agency.

Question 13

A nurse records the following at 1800: patient states that the abdominal pain is worse now than last night-Betty Smith,RN.The nurse is using which type of charting?

Accepted Answer

A)  PIE documentation 
B)  SOAP documentation 
C)  Narrative charting 
D)  Charting by exception 
A)  PIE documentation 
B)  SOAP documentation 
C)  Narrative charting 
D)  Charting by exception

Question 14

Which action should the nurse take when handling and disposing of patient information?

Accepted Answer

A)  Keep patient information to take home for disposal. 
B)  Use programmed speed-dial keys when faxing. 
C)  Throw hand-written notes about the patient in the trash. 
D)  Place fax machines in a public place. 
A)  Keep patient information to take home for disposal. 
B)  Use programmed speed-dial keys when faxing. 
C)  Throw hand-written notes about the patient in the trash. 
D)  Place fax machines in a public place.

Question 15

A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation.The nurse charts the following: Discuss alternatives for pain control.Which component of SOAP did the nurse chart?

Accepted Answer

A)  S 
B)  O 
C)  A 
D)  P 
A)  S 
B)  O 
C)  A 
D)  P

Question 16

A nursing student is working on a clinical assignment.Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor?

Accepted Answer

A)  Patient room number 
B)  Patient date of birth 
C)  Patient medical record number 
D)  Patient nursing diagnosis 
A)  Patient room number 
B)  Patient date of birth 
C)  Patient medical record number 
D)  Patient nursing diagnosis

Question 17

Which documentation by the nurse is most appropriate?

Accepted Answer

A)  "The patient states would except moving to a semi-private room." 
B)  "Developed aspiration pneumonia due to dysphasia." 
C)  "Bruise noted on right side over fractured abdimin." 
D)  "Right jugular vein distended." 
A)  "The patient states would except moving to a semi-private room." 
B)  "Developed aspiration pneumonia due to dysphasia." 
C)  "Bruise noted on right side over fractured abdimin." 
D)  "Right jugular vein distended."

Question 18

Which information by a nurse indicates more teaching is needed about The Joint Commission's requirements for writing plans of care?

Accepted Answer

A)  A care plan must be developed for patients in a clinic. 
B)  A care plan must be developed for patients in an acute care hospital. 
C)  A care plan must be developed for patients in a rehabilitation agency. 
D)  A care plan must be developed for patients in an extended care facility. 
A)  A care plan must be developed for patients in a clinic. 
B)  A care plan must be developed for patients in an acute care hospital. 
C)  A care plan must be developed for patients in a rehabilitation agency. 
D)  A care plan must be developed for patients in an extended care facility.

Question 19

Which information by the staff indicates teaching by the nurse was successful for the purposes of documentation? (Select all that apply.)

Accepted Answer

A)  To aid in clinical research 
B)  To maintain a legal and financial record of care 
C)  To include a step-by-step description of how to perform procedures 
D)  To evaluate quality process and performance improvement 
E)  To communicate patient needs and progress toward meeting outcomes 
A)  To aid in clinical research 
B)  To maintain a legal and financial record of care 
C)  To include a step-by-step description of how to perform procedures 
D)  To evaluate quality process and performance improvement 
E)  To communicate patient needs and progress toward meeting outcomes

Question 20

Which benchmarks will indicate to the nurse that the agency has computerized information systems that demonstrate "meaningful use"? (Select all that apply.)

Accepted Answer

A)  Improves quality and safety 
B)  Improves patient compliance 
C)  Improves care coordination 
D)  Improves public health 
E)  Improves hospital's reputation 
A)  Improves quality and safety 
B)  Improves patient compliance 
C)  Improves care coordination 
D)  Improves public health 
E)  Improves hospital's reputation

Exam 10: Informatics and Documentation

A nurse is using critical pathways to care for a patient.Which area will the nurse address according to the pathway?

Which documentation by the nurse best describes patient data?

A new registered nurse is working on a pediatric unit in a large teaching hospital that uses focus charting with the acronym DAR.What will the nurse be charting?

A registered nurse recently changed jobs and is now working in home health.What must the nurse chart to obtain reimbursement from Medicare,Medicaid,and private insurance companies?

A nurse is using SBAR and tells the primary health care provider that the abdomen is distended and firm with a pain rating of 8 on a 0-10 scale.Which component of SBAR did the nurse communicate?

A nurse began working at a local hospital and learned that the hospital had just instituted a "hand-off" protocol.What will the nurse be doing?

Which information indicates the nurse has a correct understanding of the purpose of a patient's medical record?

A nurse completes an incident/occurrence report on a patient who fell while walking in the hallway.The nurse completes this report for what purpose?

A nurse is preparing a discharge summary.Which item should the nurse include?

A nurse is teaching the staff about informatics and describing the key concepts.Which information should the nurse include during the teaching session?

A nurse is documenting the last entry for the day.It is 3:15 PM and the agency uses military time.Which time should the nurse enter?

Which guidelines must the nurse follow to appropriately manage electronic patient information? (Select all that apply.)

A nurse records the following at 1800: patient states that the abdominal pain is worse now than last night-Betty Smith,RN.The nurse is using which type of charting?

Which action should the nurse take when handling and disposing of patient information?

A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation.The nurse charts the following: Discuss alternatives for pain control.Which component of SOAP did the nurse chart?

A nursing student is working on a clinical assignment.Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor?

Which documentation by the nurse is most appropriate?

Which information by a nurse indicates more teaching is needed about The Joint Commission's requirements for writing plans of care?

Which information by the staff indicates teaching by the nurse was successful for the purposes of documentation? (Select all that apply.)

Which benchmarks will indicate to the nurse that the agency has computerized information systems that demonstrate "meaningful use"? (Select all that apply.)

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