Question 1

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?

Accepted Answer

A)  "Come with me and we will look at it together." 
B)  "I'm sorry; this information is confidential." 
C)  "Let me ask my supervisor if it is okay." 
D)  "You should know better than to ask me that."

Question 2

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?

Accepted Answer

A)  Problem, intervention, evaluation 
B)  Patient, interview, evaluation 
C)  Population, intervention, encourage 
D)  Plan, interview, enhance

Question 3

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?

Accepted Answer

A)  Centers for Disease Control and Prevention accredited hospital 
B)  World Health Organization hospital 
C)  The Joint Commission accredited hospital 
D)  Agency for Healthcare Research and Quality hospital

Question 4

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?

Accepted Answer

A)  Clinical information system 
B)  Computerized provider order entry system 
C)  Administrative information system 
D)  Clinical decision support system

Question 5

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

Accepted Answer

A)  Exchange judgments made about the patient's attitudes. 
B)  Include a description of how to perform procedures. 
C)  Provide a concise and organized description of the patient's normal findings. 
D)  Make walking rounds with the nurse coming on duty to review the patient's status and needs.

Question 6

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?

Accepted Answer

A)  Cost of care per patient day 
B)  Number of registered nurses 
C)  Absence of sentinel events 
D)  Documentation audits

Question 7

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?

Accepted Answer

A)  "Seems back is hurting." 
B)  "States 'My lower back hurts.'" 
C)  "Grimaces when moving; I believe patient has lower back pain." 
D)  "Appears to be uncomfortable with lower back pain."

Question 8

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?

Accepted Answer

A)  More staff may be needed. 
B)  Talk to the patients. 
C)  Less staff may be needed. 
D)  Talk to the families.

Question 9

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

Accepted Answer

A)  Withholding the medication until the physician or health care provider signs the order 
B)  Verifying the physician's or health care provider's order with the pharmacy 
C)  Reading it back to the person who gave the order 
D)  Clarifying the new medication order with another registered nurse

Question 10

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

Accepted Answer

A)  "Sm. amt. of emesis." 
B)  "150 mL of cloudy dark yellow urine." 
C)  "Had a good day." 
D)  "Looks bad."

Question 11

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?

Accepted Answer

A)  "Patient stated that fell while going to the bathroom. Physician notified." 
B)  "Nobody available to answer call bell; patient got up on own and fell." 
C)  "Patient fell because of unsafe staffing levels on unit." 
D)  "Patient waited as long as possible but nobody there to help and fell."

Question 12

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

Accepted Answer

A)  "Seems comfortable at this time." 
B)  "Is asleep, appears not to be experiencing pain." 
C)  "Apparently is not in pain because patient didn't rate it high on the scale." 
D)  "States pain is a 2 on a 0 to 10 scale."

Exam 10: Informatics and Documentation