Exam 10: Informatics and Documentation

A registered nurse is caring for an older adult patient with lung cancer.The daughter,who is also a nurse,asks to see the chart.What is the nurse's best response?

A nurse is told during orientation that the organization is very patient focused and that it uses a documentation system with the acronym PIE.What will the nurse be charting?

A nurse is working in an agency with standards that require a nurse's documentation to be within the context of the nursing process.The nurse is working for which agency?

A nurse is using a computer to locate and review laboratory test results,and chart and order sterile supplies.What type of system is the nurse using?

A nurse is giving a change-of-shift report.Which action should the nurse take?

A nurse works at a health care organization that is accredited by The Joint Commission.What is the best method for this health care organization to demonstrate that it is providing quality patient care?

A patient states that he or she is experiencing pain in the lower back.What is the best way for the nurse to document this subjective information?

The nurse manager of a large medical unit in a busy urban teaching hospital reviews the unit trends for staffing,which are determined by an acuity system.The nurse manager notices that the acuity level is high.What should the nurse manager do?

After a nurse receives a medication telephone order for a patient,what is the proper action?

Which entry by the nurse demonstrates the most accurate and safe documentation of patient care?

A nurse is frustrated about the lack of staffing for the shift.When one of the patients fell and broke a hip,the nurse documented the incident in the patient's chart.Which entry is the best way that the nurse should document what happened?

A registered nurse is documenting patient assessments.Which documentation written by the nurse is most clear?