Question 1

At 0915 the nurse repeatedly instructs the patient to remain in bed.At 0930 the nurse enters the patient's room, finds the patient on the floor, and hears the patient say, "I need pain medicine." Which should the nurse do to document this event?

Accepted Answer

A)  Label the late entry using the time of 9:15 AM. 
B)  Enclose the patient statement within quotations. 
C)  Document completion of an incident report. 
D)  Record plan to administer pain medication. B

Question 2

Nursing assistive personnel (NAP) finds a patient on the floor 30 minutes after the patient ambulated with physical therapy.What information should be charted by the NAP on the incident report?

Accepted Answer

A)  "Patient fell out of bed and landed on the floor." 
B)  "Patient found on floor.Upper side rails up.Bed in low position." 
C)  "Patient got dizzy and fell although ambulated with physical therapy earlier." 
D)  "Patient unfortunately slipped and fell." B

Question 3

The nurse runs into a co-worker whose family friend is a patient on the unit.The co-worker asks about the friend's health problems.Which is the correct response by the nurse?

Accepted Answer

A)  "Your friend told us to say nothing." 
B)  "Why don't you ask your friend now?" 
C)  "You know I can't talk about the patients." 
D)  "Well, it was really a very difficult surgery." C

Question 4

An incident report is completed as a result of the pharmacy sending the wrong medication to the unit, even though the medication wasn't administered.A student asks the nurse why this was needed.What response by the nurse is best?

Accepted Answer

A)  To make sure that the pharmacy was blamed for the error and not the nurse 
B)  To help the pharmacy identify risks and prevent this situation from occurring again 
C)  To prevent the hospital from a medical malpractice suit 
D)  To get the health care provider's attention about ordering medications

Question 5

The nursing staff are assisting nursing students in learning military time for documenting.Instruction by the nurses has been effective if the students identify that which entry reflects 40 minutes after midnight?

Accepted Answer

A)  0040 
B)  1240 
C)  0004 
D)  0400

Question 6

The nurse discovers a medication error on another nurse's documentation, so the nurse completes an incident report.Which statement should the nurse include in the report?

Accepted Answer

A)  "Nurse mistakenly gave the wrong dose of medication for pain." 
B)  "Nurse gave incorrect dose of pain medication, but patient is all right." 
C)  "Morphine 10 mg IM given rather than morphine 5 mg IM as ordered." 
D)  "Physician will be notified of error when he makes rounds tomorrow."

Question 7

The nursing staff have been using the SBAR format to structure communication for the past few months.Successful implementation of this system would be present if the nurse manager made which statement?

Accepted Answer

A)  "There are fewer omissions in patient care than before implementing this system." 
B)  "Fewer nurses are coming in late when they are scheduled to work." 
C)  "The medications are given on time now." 
D)  "The patient length of stay has decreased since last year."

Question 8

The nurse is documenting on a patient with a respiratory problem.Which patient datum documented by the nurse is the least objective?

Accepted Answer

A)  Cool and dusky skin 
B)  Low flow rate oxygen 
C)  30 breaths per minute 
D)  Very restless and drowsy

Question 9

The nurse is documenting the care of a patient.Which entry would be characteristic of charting by exception (CBE) as a documentation method?

Accepted Answer

A)  The patient needed to be turned every hour because of increasing pain. 
B)  The patient's vital signs are stable. 
C)  The patient's gait was steady with assistance from physical therapy. 
D)  There was no odor when the dressing was removed.

Question 10

The nurse is providing home care for a patient with an infection that is not improving.The patient refuses to see an infectious disease specialist.What should the nurse include in the documentation of the patient teaching provided?

Accepted Answer

A)  The discussion about the consequences of refusing to see a specialist and the patient's response. 
B)  The explanation that avoiding the specialist will most likely lead to a worse outcome. 
C)  A hopeful explanation that this will most likely be the last medical specialist that the patient will need to see. 
D)  The recommendation that the patient should discuss the decision with the family.

Question 11

Electronic health records (EHRs) can improve patient care.The following is an example of an alert in an EHR.(Select all that apply.)

Accepted Answer

A)  Notification of medication being overdue 
B)  Change in patient's blood pressure that exceeds parameters 
C)  Order entered for a medication the patient is allergic to 
D)  Routine lab orders 
E)  Critical lab value

Question 12

In a POMR charting method of documentation, which of the following items are used? (Select all that apply.)

Accepted Answer

A)  Progress notes 
B)  Database 
C)  Medical diagnosis 
D)  Problem list 
E)  Care plan

Question 13

The Joint Commission standards require all patients admitted to a health care agency to have the following documented.(Select all that apply.)

Accepted Answer

A)  Self-care assessment 
B)  Discharge planning needs 
C)  Environment assessment 
D)  Physical assessment 
E)  Religious practices

Question 14

A nurse passes by a computer screen that has patient information that can be seen by visitors.What is the appropriate action for the nurse to take at this time?

Accepted Answer

A)  Leave the computer screen alone. 
B)  Try to find the nurse caring for this patient. 
C)  Document this situation on an incident report. 
D)  Close the computer screen.

Question 15

The following is an excerpt of a discharge planning note.What elements of discharge planning are present in this example? (Select all that apply.) "Discussed learning about insulin injection technique.Patient will administer his own injection next time."

Accepted Answer

A)  Measurable patient goal 
B)  Progress toward goal 
C)  Need for referral 
D)  Discharge date

Question 16

The following is an example of what part of the SBAR communication mnemonic? "Her blood pressure has decreased from 140/90 to 100/50 and she vomited 400 mL of bright red blood."

Accepted Answer

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

Exam 3: Documentation and Informatics