Passpoint: Informatics practice questions
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."
A nurse is teaching a client about simple wound care. The client insists on using a smartphone to record the procedure. What is the nurse's best response to the client?
"I will need to clarify with my manager if you can record the procedure."
A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for their personal identification number (PIN) to log in. What is the nurse's best response?
"I'll be happy to contact Information Services to assist you with the problem."
A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. The client requests that their evaluation and counseling records be e-mailed to the client's Human Resources representative. How should the nurse respond?
"It's best not to e-mail your personal records because doing so might put your privacy at risk."
A facility has just instituted a new electronic health record, and a group of nurses have been asked by the department to share their views on the new system. Which statement by the nurses would be a cause for concern, requiring some revision to the system?
"It's nice not to have to sign back in to gain access if we walk away from the terminal."
A client comes to the clinic for evaluation. The client tells the nurse, "I have been having headaches and dizziness. I looked it up on the Internet, and I think I might have a brain tumor." The client hands the nurse a printout of what the client found. Which response by the nurse would be most appropriate?
"Tell me more about where you found this information you gave me"
A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information?
1 Unit of glucose
The nurse in a long-term care facility has just administered medication to three clients. Each client takes the same medication one right after another, and the nurse documents each individually according to their times: 3:30 pm, 3:35 pm, 3:40 pm. The electronic system only accepts military time input. How should the nurse enter the time in the computer for each client?
1530, 1535, 1540
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
WebQuest
An inquiry-based learning project utilizing information from preselected Web sites.
A nurse is caring for a client with a prescription for hydromorphone 2 mg I.V. as needed for pain. The client is reporting pain at a 10/10 and is requesting to be medicated. When trying to retrieve the prescribed hydromorphone, the nurse is unable to access the computerized automated dispensing cabinet (ADC) because of an expired password. What is the most appropriate action by the nurse?
Ask another nurse to administer the medication to the client while contacting information services to reset password.
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.
A nurse is entering client data into the EHR. Which of the following protects the integrity of the client data in the EHR?
Authentication
Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next?
Check the computerized care plan to determine what test was scheduled.
A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error. How should the nurse correct the error made in documentation?
Cross out the incorrect statement with a single line.
International Classification of Nursing Practice
INCP focuses on nursing diagnoses, outcomes, and actions rather than numerical data
The nurse is providing care to multiple clients within a tight time frame. The nurse inserted a urinary (Foley) catheter for a client but had to address an emergency incident with a separate client before documenting the catheter insertion. Which information should the nurse add to the documentation to ensure accurate medical records?
Include the date and time of the insertion
A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation?
Inform the other nurse that the viewed screen resulted in a breach of confidentiality.
A nurse caring for a client being treated by three health care providers uses the source-oriented format for documentation. What are the benefits of using this format of documentation?
Information is documented in separate forms by each health care professional.
Nurses at a health care 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.
Nursing Management minimum data set
NMMDS a standardized nursing terminology that focuses on numerical data, such as cost analysis figures, and provides a framework of uniform entry and management of data
A nurse is caring for a client at the local health care 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.
A health care 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.
Systematic Nomenclature of Medicine
SNOMED retired system by the committee for nursing practice information infrastructure
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.
AHRQ (Agency for Healthcare Research and Quality)
Supports research that improves the quality of health care and helps people make informed health care decisions, develops partnerships that create long term improvement in America health care, research goals measure improvements in terms of client outcome, decreased mortality, improved quality of life and cost effective quality care, and focus on safety and quality, effectiveness, and efficiency
clinical information systems
Systems that provide for organized processing, storage, and retrieval of information to support patient care processes and allow for an interdisciplinary approach when planning care for a client by increasing the healthcare teams access to information.
experienced informatics nurse
The experienced informatics nurse interprets trends in data entered in client outcomes
informatics innovator
The highest level of competency is the informatics innovator. This level includes the design and development of new applications to improve client outcomes.
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.
omission
a documentation error in which information is missing from the medical record
source oriented documentation
a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client's care.
problem oriented documentation
a unified, cooperative approach for resolving the client's problems compiled to facilitate communication among health care professionals.
charting by exception
an abbreviated form of documentation
late entry
an entry made later than it should have been.
CINAHL (Cumulative Index to Nursing and Allied Health Literature)
an online evidence based resource and information system that offers a multitude of online services, which includes web site link sources, online nursing and allied health databases, document delivery, and search services
A client with end-stage pulmonary hypertension tells the health care provider they don't want any heroic measures should their heart stop, and don't want to be placed on a ventilator. The health care provider 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 working in a new orthopedic unit is asked to initiate the practice of an abbreviated form of documentation, which requires less nursing time and readily detects changes in client status. Which documentation method should the nurse suggest?
charting by exception
An EHR helps:
develop a plan of care
unauthorized entry
documentation for another nurse or HCM A nurse shouldn't document for another nurse, except for an authorized entry in an emergency
A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when
documenting medications after administration
A health care provider 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 they can safely use the same irrigation set for their 8-hour shift if they cover 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
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 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 managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?
narrative notes
source oriented documentation
organized at numerous locations; there is not one location for information.
The FOCUS system of documentation
organizes entries by data, action, and response broader in its view because a focus can be a problem area, but does not need to be
National Database of Nursing Quality Indicators (NDNQI)
provides data from multiple facilities for profiling and comparison. Allows data to be analyzed and isolates the issues that require attention
The problem, intervention, and evaluation note system
simplifies documentation by incorporating the plan of care into the progress notes.
The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply.
to ensure efficient and accurate communication to prevent medication errors to ensure client safety
A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that they gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error?
unauthorized entry
informatics nurse specialist
uses data to identify informatics and client care needs but does NOT create new applications
While responding to a client's call for help, the nurse finds the client lying on the floor. After assisting the client to bed and performing an assessment, the nurse informs the health care provider. In completing an incident report, the nurse documents that the client:
was found lying on the floor
A nurse is caring for a client who has a pacemaker and requires telehealth monitoring. Which of the following is a benefit from using this type of telehealth?
wireless technology allows cardiac data to be downloaded in real time from the clients pacemaker.
