Exam 4 - ATI and Evolve questions + Knowledge check (19-24)

ATI: Documentation A nurse is preparing to administer morphine 15 mg PO every 4 hour for PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication? A. By mouth B. Intramuscularly C. Per rectum D. Intravenously

A. By mouth

ATI: Documentation A newly licensed nurse is orienting to a facilities documentation process. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods? A. Charting by exception B. Subjective, objective, assessment, plan format C. Problem, intervention, evaluation model D. Data, action, response charting

A. Charting by exception

ATI: Informatics A nurse is completing a medication reconciliation on a newly admitted client. Which of the following information should the nurse include? (Select all that apply.) A. Current prescribed medications. B. Nutritional supplements the client takes. C. Over-the-counter medications the client uses. D. Medications the provider has discontinued. E. List of vitamins the client has stopped taking.

A. Current prescribed medications. B. Nutritional supplements the client takes. C. Over-the-counter medications the client uses.

ATI: Informatics A nurse is reviewing the role of health information technology in client care with a newly licensed nurse. Which of the following information should the nurse include? (Select all that apply.) A. Facilitates care coordination. B. Increase human error. C. Improves practice efficiencies. D. Is capable of being overridden by a nurse. E. Improves clinical outcomes.

A. Facilitates care coordination. C. Improves practice efficiencies. D. Is capable of being overridden by a nurse. E. Improves clinical outcomes.

ATI: Informatics A nurse is assisting with teaching a class about HIPAA. Which of the following information should the nurse include? (Select all that apply.) A. HIPAA protects the unauthorized release of a client's protected health information. B. HIPAA prohibits clients from obtaining their medical record. C. HIPAA requires notification of a breach of privacy via an in-person report. D. The loss of a provider's cell phone that contains a client's protected health information is considered a data breach. E. A breach in HIPAA should be reported within 60 days after the breach is discovered.

A. HIPAA protects the unauthorized release of a client's protected health information. D. The loss of a provider's cell phone that contains a client's protected health information is considered a data breach. E. A breach in HIPAA should be reported within 60 days after the breach is discovered.

ATI: Documentation A nurse is talking with a client about the electronic health record at the facility. Which of the following client statements indicates an understanding of EHRs? A. I will be able to track my health information. B. My personal information will be entered into a national database. C. I will have one EHR that will encompass the health care I've received over my lifetime. D. The goal of EHRs is to improve insurance coding.

A. I will be able to track my health information.

ATI: Documentation A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? A. Immunization data B. Record of client health care payments C. Complete medical information for household members D. Facility policies

A. Immunization data

ATI: Documentation A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's do not use list? (select all that apply) A. MSO4 B. IU C. PO D. qhs E. NKA

A. MSO4 B. IU D. qhs

ATI: Informatics A nurse is teaching a class about using smart infusion pumps to administer intravenous medications. Which of the following information should the nurse include? A. Nurses enter client information into the smart infusion pump. B. Nurses should use workarounds when using smart infusion pumps. C. The use of smart infusion pumps is associated with increased medication errors. D. The smart infusion pump alerts the nurse when the setting is within the safety limits.

A. Nurses enter client information into the smart infusion pump.

ATI: Documentation A nurse in the clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? A. PRN B. NPO C. AC D. Ad lib

A. PRN

ATI: Documentation A charge nurse reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include? (select all that apply) A. Reduces medical errors B. Improves listening skills among interdisciplinary team members C. Less convenient than paper-based charting D. Makes client medical history more easily available E. Increases the accuracy of coding procedures

A. Reduces medical errors D. Makes client medical history more easily available E. Increases the accuracy of coding procedures

ATI: Informatics A nurse is assisting with teaching a newly licensed nurse about the use of electronic health records (EHRs). Which of the following is an outcome associated with the use of EHRs that the nurse should include? A. Saves time. B. Decreases quality of care. C. Creates redundancy. D. Increases cost.

A. Saves time.

ATI: Documentation A nurse manager is reviewing the documentation for newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly? A. Synthroid 100 mg PO every morning ac B. Enoxaparin 75 mg SQ bid C. Digoxin 0.25 mg PO qd D. Metformin 500.0 mg PO with evening meal

A. Synthroid 100 mg PO every morning ac

ATI: Documentation A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify which of the following agencies advocated for the nationwide use of EHRs? A. The Institute of Medicine B. Department of Veteran Affairs C. American Hospital Association D. The Joint Commission

A. The Institute of Medicine

ATI: Documentation A nurse is caring for a client after a stroke. The nurse should recognize which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? (select all that apply.) A. The admitting provider B. The charge nurse on the unit C. The client's sibling D. The client E. The client's spiritual advisor

A. The admitting provider B. The charge nurse on the unit D. The client

ATI: Documentation A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following should the nurse include as a benefit of electronic documentation? A. The system alerts providers of possible actions that could cause client harm. B. An electronic system prevents breaches of confidentiality of client data. C. Providers can document client information in the electronic record during system downtime. D. System encryption eliminates the need for security firewalls.

A. The system alerts providers of possible actions that could cause client harm.

ATI: Informatics A nurse is assisting with teaching a class about using simulation for clinical education. Which of the following information should the nurse include? A. The use of simulation improves communication skills. B. Simulation should be used in place of clinical practice. C. Simulation is a component of nursing theory. D. The use of simulation is expected to decrease.

A. The use of simulation improves communication skills.

ATI: Documentation A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information? A. "I can take a telephone prescription if a provider is making routine rounds in another area of the facility." B. "I can take a telephone prescription if a provider is directing a code for an unresponsive client." C. "If a client requires an over-the-counter medication for the relief of nausea, it is okay to accept a telephone prescription." D. "If a client requires pain control for a terminal condition, it is okay to accept a telephone prescription."

B. "I can take a telephone prescription if a provider is directing a code for an unresponsive client."

ATI: Documentation A nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following should the nurse include? A. Providers designate to other staff which abbreviations cannot be used. B. A nurse who delegates a task to an AP will review the charting for that task. C. Providers read and cosign nursing documentation for accuracy. D. Licensed personnel should document out-of-range vital signs for AP.

B. A nurse who delegated a task to an AP will review the charting for that task.

ATI: Informatics A nurse is reviewing discharge instructions with a client who has low health literacy. Which of the following actions should the nurse take? A. Speak quickly. B. Provide examples. C. Discourage questions. D. Use medical terminology.

B. Provide examples.

ATI: Documentation A nurse is documenting information in a client's chart and makes the entry quotation mark client reports "abdominal pain on exertion". Which of the following documentation format describes this entry? A. The "I" in PIE B. The "S" in SOAP C. The "R" in DAR D. The "E" in PIE

B. The "S" in SOAP

ATI: Documentation A nurse is reviewing the documentation of a newly licensed nurse. Which of the entries should the nurse identify as meeting the American Nurses Association (ANA) standards of documentation?" A. The client is now asleep, and they ate most of their breakfast a few hours ago. B. The client vomited 240 mL of clear emesis but denies pain or nausea. C. The client reports not feeling good, but they look fine. D. The client has 8 to 10 sores on their body."

B. The client vomited 240 mL of clear emesis but denies pain or nausea.

ATI: Informatics A nurse is reviewing the HIPAA regulatory rules. Which of the following rules is restricted to electronically protected health information (e-PHI)? A. The privacy rule B. The security rule C. The breach notification rule D. The enforcement rule

B. The security rule

ATI: Informatics A nurse is assisting with teaching a client about remote patient monitoring (RPM) devices. Which of the following information should the nurse include? (Select all that apply.) A. The client needs to confirm the data before it is transferred to the provider. B. The transfer of data is accomplished using wireless devices. C. Clients can participate in their health by using RPM. D. A client's heart rhythm can be transferred using RPM. E. Data collected using RPM is not considered protected health information.

B. The transfer of data is accomplished using wireless devices. C. Clients can participate in their health by using RPM. D. A client's heart rhythm can be transferred using RPM.

ATI: Informatics A nurse is assisting with teaching a class about using health information technology for client care. Which of the following examples should the nurse include? A. Using a roller clamp to adjust a client's IV rate. B. Using a barcode to verify a client's medication. C. Palpating a client's blood pressure. D. Wearing sterile gloves to change a client's dressing.

B. Using a barcode to verify a client's medication.

ATI: Documentation A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include? A. A problem-oriented medical record is created using the PIE model for documentation entries. B. A problem-oriented medical record contains separate sections for laboratory and diagnostic information. C. A problem-oriented medical record promotes information sharing among members of the interdisciplinary team. D. A problem-oriented medical record is rarely used in acute care settings.

C. A problem-oriented medical record promotes information sharing among members of the interdisciplinary team.

ATI: Informatics A nurse is assisting with teaching a newly licensed nurse about using barcode technology in client care. The nurse should include that barcode technology is used to reduce errors during which of the following phases of the medication process? A. Prescribing B. Transcribing C. Administering D. Dispensing

C. Administering

ATI: Documentation A nurse is discussing computerized provider order entry systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system? A. CPOE systems are associated with a slightly higher error rate. B. CPOE use does not include medication prescriptions. C. CPOE systems can increase the speed of care delivery. D. CPOE use is mandated by HIPAA under the Privacy Rule.

C. CPOE systems can increase the speed of care delivery.

Evolve: Informatics and technology Which type of report is given at the end of a shift so that the next nurse can follow the appropriate treatment plan and care for the patient? A. Discharge summary B. Incident report C. Hand-off report D. Telephone report

C. Hand-off report

ATI: Informatics A nurse is reviewing the impact low health literacy has on clients with a newly licensed nurse. Which of the following information should the nurse include? A. Decrease in health care costs. B. Decrease in use of emergency services. C. Increase in mortality rate. D. Increase in use of prevention services.

C. Increase in mortality rate.

ATI: Documentation A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include? A. Accessing the medical record of clients on units other than where you are assigned is allowed. B. There are large financial penalties for charting vital signs you obtain for another nurse's client. C. Personnel can be terminated for breaching a client's confidentiality. D. Once you have cared for a client, it is acceptable to look at their medical record on subsequent healthcare visits.

C. Personnel can be terminated for breaching a client's confidentiality.

ATI: Documentation A charge nurse is reviewing soap documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data? A. The client states, "I've had abdominal pain for the past 3 days." B. The client reports consuming about 1,500 mL of water per day. C. Rebound tenderness noted in RLQ of the abdomen. D. Recommend client referral to a registered dietitian.

C. Rebound tenderness noted in RLQ of the abdomen.

ATI: Informatics A nurse is reviewing the use of electronic documentation with a newly licensed nurse. Which of the following statements should the nurse make? A. "Electronic documentation increases paperwork." B. "Electronic documentation increases the time available to provide direct client care." C. "Electronic documenting takes approximately 10 percent of your time." D. "Electronic documentation provides evidence of care provided."

D. "Electronic documentation provides evidence of care provided."

ATI: Informatics A nurse is discussing clinical pathways with a newly licensed nurse. Which of the following information should the nurse include? A. Paper-based clinical pathways are more effective than computer-based. B. The use of clinical pathways has led to a decline in client outcomes. C. Insurance companies discourage the use of clinical pathways. D. Clinical pathways use evidence-based practice guidelines for health care delivery.

D. Clinical pathways use evidence-based practice guidelines for health care delivery.

ATI: Documentation A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include? A. American Nurse Association (ANA) standards prevent client records from being used for legal proceedings. B. HIPAA regulations vary from one state to another. C. Privacy regulations apply to electronic data transfer rather than verbal communication. D. Facilities can establish their own rules for documentation methods.

D. Facilities can establish their own rules for documentation methods.

ATI: Informatics A nurse is preparing to use a video-enabled device to communicate with a client who is at home. Which of the following actions should the nurse plan to take? A. Record the video conference to use as an educational tool. B. Inform the client that telemedicine restricts access to nursing care. C. Use a speakerphone in a semi-private location during the video conference. D. Instruct the client to use a computer for the video conference.

Instruct the client to use a computer for the video conference.