Question 1

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?

Accepted Answer

A)  The student nurse reads the patient's plan of care. 
B)  The student nurse reviews the patient's medical record. 
C)  The student nurse shares patient information with a friend. 
D)  The student nurse documents medication administered to the patient.

Question 2

A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.)

Accepted Answer

A)  Communication 
B)  Legal documentation 
C)  Reimbursement 
D)  Nursing process 
E)  Research
F) Education

Question 3

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe?

Accepted Answer

A)  Varied clinical databases 
B)  Reduced errors of omission 
C)  Increased hospital costs 
D)  More time to read charts

Question 4

A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order?

Accepted Answer

A)  As the nurse and health care provider leave a patient's room, the primary care provider gives the nurse an order. 
B)  At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood. 
C)  At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order. 
D)  A nurse reads an order correctly as written by the health care provider in the patient's medical record.

Question 5

A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take?

Accepted Answer

A)  Use the same password all the time. 
B)  Share password with only one other staff member. 
C)  Print out and review computer nursing notes at home. 
D)  Chart on the computer immediately after care is provided.

Question 6

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session?

Accepted Answer

A)  Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. 
B)  A clinical information system must be installed by 2014 to obtain health care reimbursement. 
C)  A "near miss" helps determine reimbursement issues for health care. 
D)  HIPAA is the basis for establishing reimbursement for health care.

Question 7

A nurse is completing an OASIS data set on a patient. The nurse works in which area?

Accepted Answer

A)  Home health 
B)  Intensive care unit 
C)  Skilled nursing facility 
D)  Long-term care facility

Question 8

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse find?

Accepted Answer

A)  Electronic medical record 
B)  Electronic health record 
C)  Electronic charting record 
D)  Electronic problem record

Question 9

After providing care, a nurse charts in the patient's record. Which entry will the nurse document?

Accepted Answer

A)  Appears restless when sitting in the chair 
B)  Drank adequate amounts of water 
C)  Apparently is asleep with eyes closed 
D)  Skin pale and cool

Question 10

A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include?

Accepted Answer

A)  The family is a "pain." 
B)  Pupils equal and reactive to light 
C)  Had poor results from the pain medication 
D)  Sharp pain of 8 on a scale of 1 to 10

Question 11

Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)

Accepted Answer

A)  Writes the patient's room number and date of birth on a paper for school 
B)  Prints/copies material from the patient's health record for a graded care plan 
C)  Reviews assigned patient's record and another unassigned patient's record 
D)  Gives a change-of-shift report to the oncoming nurse about the patient 
E)  Reads the progress notes of assigned patient's record
F) Discusses patient care with the hospital volunteer

Question 12

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?

Accepted Answer

A)  Clinical decision support system 
B)  Nursing process design 
C)  Critical pathway design 
D)  Computerized provider order entry system

Question 13

A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up?

Accepted Answer

A)  To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice. 
B)  A nurse needs to know how to find, evaluate, and use information effectively. 
C)  If a nurse has computer competency, the nurse is competent in informatics. 
D)  Nursing informatics is a recognized specialty area of nursing practice.

Question 14

A nurse developed the following discharge summary sheet. Which critical information should the nurse add?

Accepted Answer

A)  Clinical decision support system 
B)  Admission nursing history 
C)  Mode of transportation 
D)  SOAP notes

Exam 26: Documentation and Informatics