Deck 3: Documentation and Informatics

Question 1

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?

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."

Answer 1

"Patient found on floor. Upper side rails up. Bed in low position."

Question 2

The nurse documents patient care using the SOAP format.Which should the nurse record under the "P" section?

A) AM fasting serum glucose level at 122 mg/dL
B) Patient states, "I am too tired to walk today."
C) 2 cm-diameter open area on left lateral heel
D) Check response to pain medication in 1 hour.

Answer 2

Check response to pain medication in 1 hour.

Question 3

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?

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 terrible 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

Answer 3

The discussion about the consequences of refusing to see a specialist and the patient's response

Question 4

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

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 5

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

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 6

At 9:15 AM the nurse repeatedly instructs the patient to remain in bed.At 9:30 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?

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 medication before its administration

Question 7

The nursing staff is using a worksheet that contains information for change-of-shift report and facilitates access to information when referring to the patient's computerized record.Which document is the nursing staff using?

A) The graphic sheet
B) The nursing Kardex
C) The problem-oriented medical record
D) The Joint Commission standards

Question 8

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."

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

Question 9

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?

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 10

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.Why would the nurse initiate an incident report?

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 healthcare provider's attention about ordering medications

Question 11

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?

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 12

The nursing staff has 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?

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 13

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?

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."

Question 14

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."

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

Question 15

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

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

Question 16

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

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

Question 17

The "PIE" format is used on the nursing unit.Which entry should the nurse place in the "E" part of the format?

A) Pain level 4/10 gnawing and constant.
B) Lung sounds clear bilaterally.
C) Patient states, "I don't want the blood transfusion because of the problems I had before."
D) Pain level 2/10 30 minutes after receiving pain medication.

Question 18

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

A) Self-care assessment
B) Discharge planning needs
C) Environment assessment
D) Physical assessment
E) Psychosocial assessment
F) None of the above

Question 19

The nursing staff is 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?

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