Deck 4: Documentation and Informatics

Question 1

Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000 hours.At 1000,a patient complains of feeling "light-headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.How should the nurse handle documentation for this episode?

A) Document the 1000 vital signs in the graphic record only.
B) Not report the incident because it was a transient episode.
C) Document the vital signs in the graphic and progress record.
D) Document the vital signs as 12 o'clock signs.

Answer 1

Document the vital signs in the graphic and progress record.

Question 2

The nurse manager is attempting to determine the staffing needs of the unit.One tool that she may use to determine the level of care needed would be

A) the standardized care plan.
B) the acuity record.
C) the patient care summary.
D) flow sheets.

Answer 2

the acuity record.

Question 3

Which of the following is the best example of objective charting?

A) "The patient states that he has been having severe chest discomfort."
B) "The patient is lying in bed and seems to be in considerable pain."
C) "The patient appears to be pale and diaphoretic and complains of nausea."
D) "The patient's skin is ashen and respiratory rate is 32 and laboured."

Answer 3

"The patient's skin is ashen and respiratory rate is 32 and laboured."

Question 4

Standardized care plans (SCPs)are effective ways to plan care for the patient.To be most effective,however,the SCP must be _________________.

A) objective,not subjective
B) individualized to meet the patient's needs
C) tested using a pilot project
D) inclusive of discharge planning

Question 5

Which of the following should be documented at the time of occurrence? (Select all that apply.)

A) Vital signs
B) Administration of medications
C) Preparation for diagnostic tests
D) Patient response to intervention
E) None of the above

Question 6

Which is a primary difference between care in the community and hospital care?

A) Documentation systems need to provide information for the home nurse only.
B) Computerized patient records are not an option in the community setting.
C) Services are assumed and need less documentation.
D) The patient and the family witness most of the care provided.

Question 7

Which of the following is the best example of accurate documentation?

A) "Abdominal wound is 5 cm in length without redness,edema,or drainage."
B) "OD to be irrigated qd with NS."
C) "No complaint of abdominal pain this shift."
D) "Patient watching TV entire shift."

Question 8

Nursing documentation must have which of the following characteristics? (Select all that apply.)

A) Factual
B) Organized
C) Public
D) Complete

Question 9

The unregulated care provider (UCP)tells the registered nurse (RN)that when the patient's vital signs were taken,the patient complained that she was in a lot of pain.The UCP then tells the nurse that she charted the patient's complaint when she charted the vital signs.What instruction does the nurse need to provide to the nursing assistant?

A) The UCP needs to make sure she uses the SBAR format when entering notes.
B) UCPs are not allowed to chart vital signs.
C) Only the nurse can write in the progress notes.
D) The UCP needs to write using blue ink to distinguish from the RN note.

Question 10

Which of the following provides a quick,easy reference for health care team members in assessing the patient's status,and includes specific measurements such as vital signs,intake and output,and pain assessment?

A) Flow sheets
B) Admission history forms
C) Narrative notes
D) Problem list

Question 11

The patient is ready to go home from the hospital.What does the nurse provide to the patient and his family before he leaves the facility?

A) Discharge summary
B) Standardized care plan
C) Patient care summary
D) Flow sheet

Question 12

The patient has been in the hospital for a hip replacement.According to his critical pathway,he should have his Foley catheter discontinued on the fourth day after surgery.Instead,the patient has it removed on the third day and is voiding normally with no problems.This would be a sign of

A) a negative variance.
B) positive case management.
C) a positive variance.
D) use of SBAR.

Question 13

The patient is a 24-year-old man who is diagnosed with possible human immunodeficiency virus (HIV)infection while being treated for active pneumonia.He has stated that the nurse may share test result information with his significant other but nothing else at this time.With whom may the nurse communicate regarding this information?

A) The patient's parents
B) The patient's significant other only
C) No one in the hospital until the patient says so
D) The patient's physician,significant other,and laboratory personnel

Question 14

The patient was in bed with all side rails up.During the night,the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient was not harmed,what step should the nurse take (if any)?

A) Complete an incident report and put it in the medical record.
B) Chart what happened and state that an incident report has been filled out.
C) Do nothing because the patient was not harmed.
D) Document what happened in the patient record without mentioning the incident report.

Question 15

Multidisciplinary care plans that include key interventions and expected outcomes within an established time frame are known as _______________.

A) charting by exception (CBE)
B) source records
C) focus charting
D) critical pathways

Question 16

A preprinted guideline used to care for patients with similar health problems is known as the

A) acuity record.
B) standardized care plan.
C) patient care summary.
D) flow sheet.

Question 17

Which of the following must be complied with when using the electronic health record (EHR)?

A) Only open EHRs for patients on your unit.
B) Share your password with your manager only.
C) Use the copy/paste function to save time.
D) Log out when you leave the computer.

Question 18

Nursing documentation (Select all that apply.)

A) ensures continuity of care.
B) provides legal evidence.
C) evaluates patient outcomes.
D) increases the risk of litigation.