Question 1

A nurse is discussing the advantages of standardized documentation forms in the nursing 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 B

Question 2

A preceptor is working with a new nurse on documentation.Which situation will cause the preceptor to intervene?

Accepted Answer

A)   The new nurse uses a black ink pen to chart.
B)   The new nurse charts consecutively on every other line.
C)   The new nurse ends each entry with signature and title.
D)   The new nurse keeps the password secure. B

Question 3

A patient has a diagnosis of pneumonia.Which entry should the nurse chart to help with financial reimbursement?

Accepted Answer

A)   Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.
B)   Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints.
C)   Breathing without difficulty. Sitting up in bed watching TV. Had a good day.
D)   Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours. A

Question 4

Which entry will require follow-up by the nurse manager?

Accepted Answer

A)   0800
B)   0810
C)   0815
D)   0830

Question 5

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

Accepted Answer

A)   Kardex form
B)   Admission nursing history
C)   Mode of transportation
D)   SOAP notes

Question 6

A nurse is preparing a change-of-shift report for a patient who had chest pain.Which information is critical for the nurse to include?

Accepted Answer

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

Question 7

A nurse is giving a hand-off report to the oncoming nurse.Which information is critical for the nurse to report?

Accepted Answer

A)   The patient had a good day with no complaints.
B)   The family is demanding and argumentative.
C)   The patient has a new pain medication, Lortab.
D)   The family is poor and had to go on welfare.

Question 8

A nurse obtained a telephone order from a primary care provider for a patient in pain.Which chart entry should the nurse document?

Accepted Answer

A)   12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.
B)   12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back.
C)   12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
D)   12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.

Question 9

A nurse wants to integrate all pertinent patient information into one record,regardless of the number of times a patient enters the health care system.Which term should the nurse use to describe this system?

Accepted Answer

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

Question 10

After providing care,a nurse charts in the patient's record.Which entry should 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 11

A nurse is charting on a patient's record.Which action is most accurate legally?

Accepted Answer

A)   Charts legibly
B)   States the patient is belligerent
C)   Uses correction fluid to correct error
D)   Writes entry for another nurse

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 creating a plan to reduce data entry errors and maintain confidentiality.Which guidelines should the nurse include?

Accepted Answer

A)   Create a password with just letters.
B)   Bypass the firewall.
C)   Use a programmed speed-dial key when faxing.
D)   Implement an automatic sign-off.
E)   Impose disciplinary actions for inappropriate access.F)  Shred papers containing personal health information (PHI) .

Question 14

A patient is being discharged home.Which information should the nurse include?

Accepted Answer

A)   Acuity level
B)   Community resources
C)   Standardized care plan
D)   Kardex

Question 15

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

Question 16

A nurse has taught the patient how to use crutches.The patient went up and down the stairs using crutches with no difficulties.Which information will the nurse use for the "I" in PIE charting?

Accepted Answer

A)   Patient went up and down stairs
B)   Deficient knowledge regarding crutches
C)   Demonstrated use of crutches
D)   Used crutches with no difficulties

Question 17

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

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 18

A home health nurse is preparing for an initial home visit.Which information should be included in the patient's home care medical record?

Accepted Answer

A)   Nursing process form
B)   Step-by-step skills manual
C)   A list of possible procedures
D)   Reports to third party payers

Question 19

A nurse is a member of an interdisciplinary team that uses critical pathways.According to the critical pathway,on day 2 of the hospital stay,the patient should be sitting in the chair.It is day 3,and the patient cannot sit in the chair.What should the nurse do?

Accepted Answer

A)   Focus charting using the DAR format.
B)   Add this data to the problem list.
C)   Document the variance in the patient's record.
D)   Report a positive variance in the next interdisciplinary team meeting.

Question 20

A nurse is using the source record and wants to find the daily weights.Where should the nurse look?

Accepted Answer

A)   Database
B)   Medical history and examination
C)   Progress notes
D)   Graphic sheet and flow sheet

Exam 26: Documentation and Informatics