Deck 10: Informatics and Documentation

Question 1

What is the best method for to The Joint Commission to demonstrate that it is assessing quality patient care?

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

Answer 1

Documentation audits

Question 2

The nurse realizes that the wrong patient's name was written on several important paperwork forms that were already signed by the attending physician.How will the nurse correct this error?

A) Black out the error with a thick marker and enter the correct information.
B) Use correction tape to write over the incorrect information.
C) Draw one line through the error,make the correction and initial it.
D) Shred the forms with the incorrect information and write on new ones.

Answer 2

Draw one line through the error,make the correction and initial it.

Question 3

Which entry in the patient's chart will justify home nursing care reimbursement from Medicare,Medicaid,and private insurance companies?

A) The patient's wound is improving slightly each day.
B) The patient was receptive to the smoking cessation information.
C) The patient's family appreciated the nurse's caring demeanor.
D) The patient's wound was 6 cm × 4 cm and is now 4 cm × 2 cm.

Answer 3

The patient's wound was 6 cm × 4 cm and is now 4 cm × 2 cm.

Question 4

Which statement by the nurse accurately reflects a benefit of installing a new electronic medical record system?

A) "I am thankful that I won't have to keep changing my passwords all the time."
B) "I'll be able to see my son's medical record using my password and user ID."
C) "I won't have to worry about reading the doctor's messy handwriting anymore."
D) "It will take me so much less time than writing everything out on paper."

Question 5

Which information must be shared during the hand-off report to the oncoming nurse?

A) The patient is nauseated and complaining of moderate generalized pain.
B) The patient has six children and fourteen grandchildren.
C) The patient will drink chicken broth but prefers to have lime gelatin.
D) The patient sent back the dinner tray twice because the food was cold.

Question 6

The patient requests that her chart be destroyed as soon as she is discharged.What is the best response of the nurse?

A) "The hospital can give you the chart after you are discharged."
B) "Your chart will be kept secure and confidential."
C) "The information must be reported to the health department first."
D) "Your chart can be shredded if you give consent."

Question 7

After a patient fall,the supervisor asks the nurse to rewrite the entry in the patient's chart to show that the patient's bed was lowered to the floor even though it was not.What is the best action of the nurse?

A) Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed.
B) Remind the supervisor that it is against regulations to alter or falsify the patient's chart.
C) Ask the nurse assistant to chart that the patient's bed was lowered to the floor at the time of the fall.
D) Rewrite the entry as requested but note that the patient's bed was not lowered to the floor in the incident report.

Question 8

The nurse is working at a hospital whose electronic medical records system uses charting by exception.Which entry would be appropriate to include in the narrative section of the patient's chart?

A) The patient voided 400 mL of clear yellow urine during the last 12 hours.
B) The patient denies smoking,alcohol intake,or use of illicit substances.
C) The patient states that the pain level in his right knee is 7 on a 1-to-10 scale.
D) The patient's lung sounds are clear bilaterally with no cyanosis or dyspnea.

Question 9

Which action by the nurse minimizes the risk of unauthorized use of computer passwords for the electronic medical record system?

A) Using the same password for home and health care agency computers
B) Writing each new computer password on the back of the name badge
C) Periodically reusing previous computer passwords to prevent forgetting them
D) Using passwords of at least eight characters with at least one number and symbol

Question 10

The patient's daughter requests to see the patient's medical record.What is the nurse's appropriate response?

A) "Come with me and we will look at it together."
B) "I'm sorry but that information is confidential."
C) "Let me ask my supervisor if it is okay."
D) "The doctor will have to give permission first."

Question 11

Which agency creates standards that require nursing documentation to be accurate,timely,and patient-centered?

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

Question 12

The nurse fills out an incident report after a patient fall but makes no mention of the report in the patient's medical record.What is the reason for this?

A) The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report.
B) The incident report includes the nurse's interpretations of what probably led the patient to get out of bed.
C) A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall.
D) The incident report is confidential and not intended to be used as evidence in a malpractice suit.

Question 13

Which chart entry represents appropriate documentation about the patient's pain assessment?

A) The patient appears not to be in any pain.
B) The patient is sleeping comfortably.
C) The patient always complains about being in pain.
D) The patient rated the pain at 2 on a 0-to-10 scale.

Question 14

Which chart entry reflects appropriate documentation of patient data?

A) The patient voided a moderate amount of urine.
B) The patient voided 220 mL of clear yellow urine.
C) The patient was incontinent.
D) The patient voided an adequate amount of urine for the shift.

Question 15

Which patient information may be included in the nursing student's assignment that will be turned in to the instructor after the clinical shift has ended?

A) Room number
B) Date of birth
C) Medical record number
D) Nursing diagnosis

Question 16

The patient was not able to continue along the migraine headache critical pathway after suffering a stroke.Which terminology describes this deviation from the prescribed pathway?

A) Negative variance
B) Noncompliance with the treatment plan
C) Risk-prone health behavior
D) Care plan intolerance

Question 17

The patient developed a large hematoma where the laboratory technician drew blood earlier in the shift.Which statement is appropriate to enter in the patient's chart?

A) The laboratory technician did not know what he was doing and traumatized the patient's arm.
B) The patient has a painful raised 2-inch × 2-inch hematoma on the outer left arm after venipuncture.
C) The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised.
D) The patient must have moved during the blood draw because there is a huge bruise on his left arm.

Question 18

Which is the correct military time entry for a medication that was administered at 8:30 p.m.?

A) 0830
B) 140
C) 2030
D) 2230

Question 19

Before leaving at the end of the shift,the nurse realizes that a set of patient assessments were taken earlier in the day but never charted.What is the appropriate action of the nurse?

A) Enter the assessments in the chart the next day before receiving report.
B) Do nothing because the other patient assessments were obtained during the shift.
C) Direct the nursing assistant to enter the assessments into the patient's chart.
D) Enter the assessments into the chart as a late entry with a reason for the delay.

Question 20

Which is the primary purpose of a patient's medical record?

A) To invoice the nursing services for hospital reimbursement
B) To protect the patient in case of a malpractice suit
C) To facilitate professional communication and safe health care
D) To contribute to a worldwide databank for trends in health care

Question 21

At the nursing station,the nurse receives a verbal order from the physician for a routine medication.What is the best action of the nurse?

A) Request that the doctor enter the order into the computer.
B) Repeat the order to the doctor and enter it into the computer.
C) Direct the unit secretary to enter the order into the computer.
D) Call the pharmacy to determine that the drug dosage is appropriate.

Question 22

Which patient situations require the completion of an incident report?

A) A patient almost receives the wrong medication due to unclear wording on the packaging from the pharmacy.
B) A patient repeatedly refuses to eat food from the hospital kitchen because it is always too salty or too cold.
C) A visitor trips on an icy sidewalk in the hospital parking lot and suffers a fractured wrist.
D) The nurse accidentally enters the wrong vital signs into the patient's medical record and corrects the error shortly afterward.
E) The patient dislikes male nursing staff and prefers to have only female nurses providing personal care.

Question 23

What is the priority action of the nurse immediately after receiving a medication telephone order from a physician?

A) Withhold the medication until the physician signs the order.
B) Authorize the physician's order with the pharmacy.
C) Read back the order to the physician for confirmation.
D) Double-check the order with another registered nurse.

Question 24

Which specifics of care will be included in a patient's critical pathway?

A) Refer the patient to the outpatient cardiac rehabilitation program.
B) Elevate the head of the patient's bed to ease shortness of breath.
C) Provide small meals throughout the day and encourage fluid intake.
D) Teach the patient how to use relaxation techniques to ease shortness of breath.

Question 25

The nurse is caring for a patient who climbed out of bed and fell on the floor.What will the nurse do in regard to the incident report?

A) Document how the patient was found and a description of the injuries.
B) Include recommendations for future fall prevention interventions.
C) Note in the patient's chart that an incident report was completed.
D) Indicate that the nursing assistant wasn't doing her job correctly.
E) Document fall prevention steps that were in place before the patient fell.

Question 26

Which information must be included in the patient's discharge summary?

A) The patient is to follow up with the primary care physician in 14 days.
B) The patient arrived at the hospital by ambulance with acute shortness of breath.
C) Supplemental oxygen was administered to the patient in the emergency room.
D) The patient is to have a protime (PT)level drawn daily for the next 7 days.
E) The patient is to take the prescribed antibiotic daily even after symptoms subside

Question 27

A nurse completes an incident/occurrence report after a patient fell.What is the reason for this report?

A) To compare patient fall rates between nursing units in the hospital
B) To provide justification for the hospital to fire the nurse
C) To prevent the patient from filing a malpractice lawsuit
D) To aid in the hospital's quality improvement program

Question 28

Which statement exemplifies important patient information in the change-of-shift report?

A) The patient sent his dinner tray back to the kitchen twice because the food was cold.
B) The patient keeps taking his nasal cannula off and threading it around the side rails of the bed.
C) The patient prefers to drink coffee that has cooled to room temperature with two sugars and two creamers.
D) The patient took all of the prescribed morning medications with a big glass of apple juice.

Question 29

The nurse has just completed teaching the patient how to self-administer insulin injections.Which entry in the patient's chart demonstrates that the teaching was successful?

A) The patient correctly self-administered his next scheduled dose of insulin.
B) The patient denied having any questions or concerns about the procedure.
C) Additional written instructions about how to perform the injection was provided.
D) The patient identified the steps and equipment used for the injection.

Question 30

The nurse is entering a note in the patient's medical record using the SOAP format.Which statement belongs in the Assessment section?

A) The patient stated "I started feeling short of breath after smelling strong perfume."
B) The patient is using accessory muscles and has wheezes in all lung fields.
C) Ineffective airway clearance related to exposure to environmental allergen.
D) Monitor pulse oximetry and administer nebulized bronchodilators.