informatics/Health Information Technology 1125

A nurse administers morphine sulfate as ordered for pain. The client experiences nausea and vomiting and a decrease in respiratory rate. When documenting this event in the health record, which data would be considered subjective data?

"Client seems very nauseated."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

Which are appropriate actions for protecting clients' identities? Select all that apply.

-Document all personnel who have accessed a client's record. -Place light boxes for examining X-rays with the client's name in private areas. -Have conversations about clients in private places where they cannot be overheard

A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply.

-Improvement in health care quality -Greater client engagement -Reduction in privacy breaches of client information

The hospital accreditation visitors are present on the nursing unit. What nursing actions will protect client privacy during the visit? Select all that apply.

-Log off the computer screen when not in use. -Keep the client's curtains closed when providing direct care. -Secure client's medical records in a locked cabinet.

An informatics nurse specialist is involved in the development of an electronic documentation system to be used by the nursing staff at the facility. The nurse specialist is planning to use standard terminology that focuses on both diagnoses and interventions. Which terminology set would be appropriate for the nurse specialist to consider using? Select all that apply.

-Omaha System -International Classification for Nursing Practice -Perioperative Nursing Data Set

A nurse is reading a journal article about informatics and use in health care. When reading the article, which concepts would the nurse likely expect to find as specifically related to this field? Select all that apply.

-usability -optimization -interoperability

Which client may be the most appropriate candidate for telepsychiatry?

A client whose depression does not warrant inpatient or outpatient care but who is motivated to maintain the client's health

A nursing student is preparing for a debate with another student about e-mental health. Which would the nurse include to support its use?

Ability to provide services in a variety of locations

A psychiatric mental health facility is undergoing a change from paper-based health records to electronic records. What action should the nurse prioritize in order to ensure client rights are protected?

Being vigilant to identify any potential threats to client confidentiality

The hospital nurse is using barcode medication administration software when preparing to administer medication to a client. When the scanning system cannot identify the client's identity, what is the appropriate nursing action?

Contact the pharmacy and information technology department for assistance.

Nurse A is having difficulty logging into the automated medication-dispensing system, and asks Nurse B to log in momentarily so that Nurse A is not delayed in administering client medications. What is Nurse B's appropriate response?

I will get the hospitals information systems phone number for you.

The nurse is updating the records of a 10-year-old girl who had her appendix removed. Which action could jeopardize the privacy of the child's medical records?

Letting another nurse use the nurse's log-in session.

During assessment of a client with systemic lupus erythematosus (SLE), the nurse hears a friction rub when the stethoscope is placed over the heart. Which complication of SLE will the nurse document in the medical records and report to the health care provider?

Pericarditis

An informatics nurse is reading a journal article about standard terminologies. The nurse demonstrates a need to reread the article when identifying which example as reflecting a standard terminology?

PubMed

A healthcare provider (HCP) calls the hospital unit and requests to leave a new prescription for a client over the phone as the HCP does not have access to the electronic health record (EHR) at present. What action would the nurse take?

Receive the prescription over the phone and repeat it back to the HCP to verify accuracy

A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first?

Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed.

The nursing student is having difficulty obtaining a mobile computer for the purpose of administering medications using the electronic medical record. The student has been reprimanded for delivering medications late in the past and wants to ensure timely administration. What action should the student take?

Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one.

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes?

Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response?

Tactfully request the provider to input the order into the computerized provider order system.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

An informatics nurse specialist is working with a group of nurses who are tasked to test a new electronic health record system. Which phase would the group be involved with as the last phase of testing?

User acceptance

The unlicensed nursing assistant is viewing the electronic medical record of an assigned client. When the assistant tries to access notes made by the social worker, an error message appears on the screen that reads, "You are not authorized to view this information." The assistant questions the nurse about this message. What response would the nurse make?

You are not authorized to view all of the details on the client.

A nurse is documenting a client's vital signs, height, and weight in the electronic health record. Applying the framework for informatics practice, the nurse would identify these values as which component of the framework?

data

An informatics nurse specialist is describing the framework underlying informatics practice. Which component of the framework would the nurse specialist describe as discrete entities without interpretation?

data

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

limiting abbreviations to those approved for use by the institution

A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff?

logging off a computer containing client information

An informatics nurse is participating in an online continuing education course about nursing informatics. The nurse demonstrates successful comprehension of the course by identifying which individual as being considered the first informatics nurse?

lorence Nightingale

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as

moxifloxacin 400 mg daily

The nurse is caring for a client with a fungal infection. The healthcare provider's prescription states the administration of fluconazole "b.i.d." How will the nurse administer the medication?

twice daily

Several nurses are discussing their impressions of the newly implemented electronic health record with an informatics nurse specialist. They say, "There is so much information on one screen, it hard to tell what we should do first. It's not really clear." The informatics nurse specialist interprets the comments as reflecting an issue with which area?

usability

An informatics nurse specialist is conducting an in-service education program for a group of staff nurses. The topic is ensuring electronic client data is secure and private. The specialist determines that the teaching was successful when the group identifies which aspect as essential to ensuring the security of electronic data when using clinical systems?

use strong passwords