Deck 10: Informatics and Documentation

Question 1

A nurse is documenting the last entry for the day.It is 3:15 PM and the agency uses military time.Which time should the nurse enter?

A) 315
B) 0315
C) 1315
D) 1515

Answer 1

1515

Question 2

Which documentation by the nurse is most appropriate?

A) "The patient states would except moving to a semi-private room."
B) "Developed aspiration pneumonia due to dysphasia."
C) "Bruise noted on right side over fractured abdimin."
D) "Right jugular vein distended."

Answer 2

"Right jugular vein distended."

Question 3

Which information indicates the nurse has a correct understanding of the purpose of a patient's medical record?

A) To invoice the nurse for reimbursement
B) To protect the patient in case of a malpractice suit
C) To ensure everyone is working toward a common goal of providing safe care
D) To contribute to a worldwide databank for trends in health care

Answer 3

To ensure everyone is working toward a common goal of providing safe care

Question 4

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?

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 5

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?

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

Question 6

Which documentation by the nurse best describes patient data?

A) "Moderate amount of clear yellow urine voided."
B) "Voided 220 mL clear yellow urine."
C) "A small amount of urine voided into absorbent pad."
D) "Patient incontinent of urine."

Question 7

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

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

Question 8

A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation.The nurse charts the following: Discuss alternatives for pain control.Which component of SOAP did the nurse chart?

A) S
B) O
C) A
D) P

Question 9

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?

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

Question 10

A nursing student is working on a clinical assignment.Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor?

A) Patient room number
B) Patient date of birth
C) Patient medical record number
D) Patient nursing diagnosis

Question 11

A new registered nurse is working on a pediatric unit in a large teaching hospital that uses focus charting with the acronym DAR.What will the nurse be charting?

A) Data, assessment, reaction
B) Data, assessment, recommendation
C) Data, actions, response
D) Data, actions, recovery

Question 12

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

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."

Question 13

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?

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

Question 14

Which information by a nurse indicates more teaching is needed about The Joint Commission's requirements for writing plans of care?

A) A care plan must be developed for patients in a clinic.
B) A care plan must be developed for patients in an acute care hospital.
C) A care plan must be developed for patients in a rehabilitation agency.
D) A care plan must be developed for patients in an extended care facility.

Question 15

A nurse began working at a local hospital and learned that the hospital had just instituted a "hand-off" protocol.What will the nurse be doing?

A) Performing transfer reports
B) Completing IV fluid flow sheets
C) Using standardized care plans
D) Reviewing laboratory reports

Question 16

A registered nurse recently changed jobs and is now working in home health.What must the nurse chart to obtain reimbursement from Medicare,Medicaid,and private insurance companies?

A) Patient's response to care
B) Whether patient had a good or bad day
C) Whether family liked nurse or not
D) Patient's number of marriages

Question 17

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?

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 18

A nurse is using SBAR and tells the primary health care provider that the abdomen is distended and firm with a pain rating of 8 on a 0-10 scale.Which component of SBAR did the nurse communicate?

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

Question 19

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?

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 20

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?

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 21

Which action should the nurse take when handling and disposing of patient information?

A) Keep patient information to take home for disposal.
B) Use programmed speed-dial keys when faxing.
C) Throw hand-written notes about the patient in the trash.
D) Place fax machines in a public place.

Question 22

Which guidelines must the nurse follow to appropriately manage electronic patient information? (Select all that apply.)

A) Never share passwords with co-workers.
B) Only the supervisor should have the nurse's password and it should be stored in a protected place.
C) Leave the computer terminal unattended when logged on.
D) Avoid leaving patient information displayed on a computer where others can see it.
E) Keep the same password for as long as the nurse works at the agency.

Question 23

Which information by the staff indicates teaching by the nurse was successful for the purposes of documentation? (Select all that apply.)

A) To aid in clinical research
B) To maintain a legal and financial record of care
C) To include a step-by-step description of how to perform procedures
D) To evaluate quality process and performance improvement
E) To communicate patient needs and progress toward meeting outcomes

Question 24

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

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 25

Which benchmarks will indicate to the nurse that the agency has computerized information systems that demonstrate "meaningful use"? (Select all that apply.)

A) Improves quality and safety
B) Improves patient compliance
C) Improves care coordination
D) Improves public health
E) Improves hospital's reputation

Question 26

A nurse is teaching the staff about informatics and describing the key concepts.Which information should the nurse include during the teaching session?

A) Wisdom
B) Charting
C) Assessment
D) Evaluation

Question 27

A nurse is using critical pathways to care for a patient.Which area will the nurse address according to the pathway?

A) Activity
B) Nursing diagnosis
C) Times to chart
D) Admission form

Question 28

A nurse records the following at 1800: patient states that the abdominal pain is worse now than last night-Betty Smith,RN.The nurse is using which type of charting?

A) PIE documentation
B) SOAP documentation
C) Narrative charting
D) Charting by exception

Question 29

A nurse is preparing a discharge summary.Which item should the nurse include?

A) Provision for follow-up care
B) Patient status at admission
C) Standardized nursing care plan
D) Detailed description of nursing procedures

Question 30

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?

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

Question 31

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

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 32

A nurse completes an incident/occurrence report on a patient who fell while walking in the hallway.The nurse completes this report for what purpose?

A) To exchange information among health care members
B) To provide information about patients on one unit to another
C) To prevent a legal lawsuit from the patient
D) To aid in the hospital's quality improvement program