informatics/Health Information Technology PrepU

The nurse is preparing to administer oral medication to a client. Which is the first action the nurse will take?

Compare the medication administration record (MAR) with the written medical order.

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

Which are appropriate actions for protecting clients' identities?

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 computerized information system developed to classify client outcomes is the:

Nursing Outcome Classification system

A nurse is caring for a client at the local healthcare facility. Which ensures that legislation related to client confidentiality is implemented at the facility?

Place in private areas light boxes for examining x-rays with the client's name.

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.

The nurse is providing care for a child in a pediatric practice that serves as a medical home for their clients. The nurse is aware the medical home for the child involves which characteristic?

This is a medical practice that coordinates the child's health care.

An adolescent reports a small (0.2 cm), round, serous-filled spot at the corner of the mouth. How should the nurse document this finding?

Vesicle

A medical/surgical nurse has been floated to the pediatric unit. Which action by the float nurse would require the pediatric nurse to intervene?

asking the child his or her name prior to giving medications

The nurse started a peripheral intravenous line in a client's left forearm. What should the nurse include in the documentation?

condition of the site size of the intravenous catheter date intravenous catheter placed location where intravenous access placed

If a manual end-of-shift count of controlled substances isn't correct, the nurse's best action is to

immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy.

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

legal document.

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

An informatics nurse is assisting with the design of an clinical information system for use by the staff of a health center. The nurse is working to ensure that the system reflects usability by making sure that the screen display is visually clean and uncluttered and that it provides only the information needed for decision making. Which concept of usability is the nurse incorporating?

simplicity

Which information is the nurse expected to find on the nursing Kardex?

the level of activity for the client the current medical order for the client the client's preparedness for an investigation

A client's record can be more accurate if the nurse:

uses point-of-care documentation.

A high school athlete has developed a fungal infection between the toes where it is red, sore, and cracked into the dermis. Which term is the most accurate for the nurse to document in the client's record?

A fissure

Which challenge associated with technology most affects nurses today?

Client privacy issues within the social media realm

An informatics nurse specialist is preparing a presentation on nursing informatics for a group staff nurses. The group will be participating in the implementation of a new electronic system to support improved client care delivery. When describing the concepts that are key to nursing informatics, which concept would the informatics nurse specialist include?

Data Information Knowledge Wisdom

An informatics nurse specialist is working with a team to design a clinical information system. To ensure system usability, the team would make sure that the language meets which criterion?

Familiarity for the user Clarity Conciseness

Nurses at a healthcare facility maintain client records using a method of documentation known as charting by exception. Which is a benefit of this method of documentation?

It provides quick access to abnormal findings.

Which statements are true about informatics in nursing practice?

Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making.

An informatics nurse is involved in testing an update to a clinical information system. Numerous caregivers are using the system at the same time. The testing is being done to see if the system can handle the large amount of users at one time. The nurse is involved with which type of testing?

Performance

The nurse is recording information in the electronic health record for a client with dehydration who is at risk for skin breakdown. Which documentation demonstrates an area of insensible fluid loss for this client?

temperature

The nurse is documenting a history on an 8-year-old client. Which item is priority for the nurse to include?

the client's immunization record

A nurse is attending a job fair at the local community center and stops at a booth that is demonstrating technology for client care. While touring the booth, the nurse meets an informatics nurse specialist (INS). Being unfamiliar with this position, the nurse asks the INS, "How did you get this position?" Which response by the nurse would be most appropriate?

"I've had graduate-level education focusing on informatics."

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate?

"It combines nursing science with information management and analytical sciences."

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which choice?

A referral.

An informatics nurse is assisting with the development of a new clinical information system that will be implemented in the facility. As part of the process, the team is evaluating the purpose of the system and the technological options available. The team is in which phase of the system development lifecycle?

Analyze and plan

An informatics nurse specialist is involved in the development of a clinical system in a facility. As part of this process, the nurse is applying the system development lifecycle. Place the phases of the system development lifecycle in the order that they would occur from first to last.

Analyze and plan Design and build Test Train Implement Maintain and evaluate

An informatics nurse specialist is teaching a group of health care providers about the different capabilities available for using electronic information and telecommunications technologies. When describing telehealth, which service would the nurse address as being supported?

Long-distance imaging review Videoconferencing Provider training Administrative meetings Client health-related education

The nurse on the surgical unit is passing 0900 medications to a client using an electronic medication administration record (eMAR). Place the medication steps in the correct sequential order (from first to last) for safe medication administration by the nurse.

Open the computer program and enter the user ID and password. Select the correct client from the list of clients. Access the client's eMAR and select/prepare the medication(s) for 0900. Verify the client's name, birthday, and armband against the eMAR. Administer and document the medications in the eMAR. Log out of the client's eMAR and monitor the client for any reactions.

A nurse is reviewing the medical record of a client at the clinic. The nurse notes that the medication and dosage prescribed for the client was based on information gathered about the client's genetic makeup from the electronic health record. The nurse interprets this as:

Pharmacogenomics

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.

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.

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

Which strategy would provide the most effective form of change of shift report?

Utilizing a reporting form and allowing time for any questions.

A client with end-stage pulmonary hypertension tells the physician they don't want any heroic measures should their heart stop, and doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is the nurse upholding by supporting the client's decision?

autonomy

A nurse is preparing to administer medications. What information does the nurse need regarding the prescription?

dosage name form

A physician enters a computer order for a nurse to irrigate a client's nephrostomy tube every 4 hours to maintain patency. The nurse irrigates the tube using sterile technique. After irrigating the tube, the nurse decides that she can safely use the same irrigation set for her 8-hour shift if she covers the set with a paper, sterile drape. This action by the nurse is

inappropriate because irrigation requires strict sterile technique.

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

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 nurse used a secure access code to obtain a morphine 2 mg/ml vial from the computerized automated dispensing cabinet (ADC). Before exiting the system, the nurse is prompted to count the remaining vials. The nurse counts 10 remaining vials, but the system reads 9 remaining vials. What is the next action by the nurse?

Ask another nurse to assist with following the procedure to resolve the discrepancy.

An informatics nurse specialist working at an ambulatory care center is interviewing clients about their experiences in using the center's patient portal. A majority of the clients have voiced dissatisfaction, stating that they "find the display screen confusing and are not sure what to click on to get the necessary information." They also talk about difficulties in trying to find their test results. Based on this information, the nurse specialist identifies a need to talk with the information technology team about ways to make the portal easier for clients to use. The informatics nurse specialist is demonstrating which ANA informatics competency?

Collaboration

The nurse is reviewing a health care provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action?

Contact the health care provider to clarify the orders.

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.

An informatics nurse specialist is collecting data from the clinical information system about the demographics of individuals diagnosed with heart failure admitted to the facility over the past five years. The nurse specialist is preparing a presentation to the facility's executive board. To promote understanding of this complex information, the nurse specialist prepares the data results using a pie chart and a bar graph. The nurse specialist is using which area of analytics?

Data visualization

An informatics nurse specialist is working as part of a team that will be developing and implementing a new client assessment tool. During which phase of the system development lifecycle would the team be integrating information about workflow patterns, standard terminology, and recommendations for screen layout from supportive research?

Design and build

An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?

Identify clients at risk for infection

Which statement is not true regarding a medication administration record (MAR)?

If the client declines the dose, the nurse does not have to document this on the MAR.

The reason that governments carefully regulate treatment given in licensed health care facilities, particularly long-term care facilities, is expressed by which statement?

Older adult clients are vulnerable.

An informatics nurse is part of a team that is testing a new electronic health record system. The testing involves large groups of health care providers who will be using the system. During this testing, the system stalls and fails to respond when large numbers of providers are using the system at the same time. Which phase of testing is being conducted?

Performance

An informatics nurse specialist is extracting data from the facility's electronic health record in an attempt to identify clients at risk for developing catheter-related bloodstream infections. When gathering this data, the nurse specialist is using which technique?

Predictive analytics

An informatics nurse specialist is conducting a seminar on the emergence of telehealth and its importance in health care delivery. The nurse specialist determines that additional discussion is needed when the group identifies which aspect as an advantage of this technology?

Promote the development of new health care services

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?

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

A nurse pages a client's primary care physician in response to a low blood pressure reading. When returning the nurse's page, the physician asks the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order?

Write "T.O." after the order and write out the physician's and nurse's names.

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

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

An informatics nurse specialist is working on a team that is considering a new technological system for the facility. Which aspect would be most important for the team to do as the first step?

Determine the need or problem to be solved