Chapter 26 EAQ

Which place is appropriate to document urine output in the patient's chart?

Flow sheet

A critical pathway for an orthopedic unit indicates that a patient should be afebrile, normotensive, and eupneic after knee-replacement surgery. The nurse performs a postoperative examination of a patient's status after left knee-replacement surgery and finds that the patient is experiencing a low-grade temperature. Which term describes this finding?

Variance

Which option is important to consider when designing a teaching form for patients being discharged?

Use of words the patients can understand when writing the directions is critical

Which statement made by the nurse is true regarding clinical information systems (CIS)?

"I can order supplies from other departments with the CIS."

Which statement requires correction regarding legal guidelines of handwritten documentation?

"I should leave spaces with unknown information blank."

Which statement made by a student nurse indicates the need for additional teaching?

"The subjective and objective data are included in problem-intervention-evaluation (PIE) charting."

Which statement indicates that the nurses understand the major advantage of using computerized provider order entry (CPOE)?

"Transcription errors are reduced when using CPOE."

Which electronic health record (EHR) information would the nurse include in teaching?

-All pertinent patient information is integrated into one record -Checks are performed by the EHRs to support regulatory requirements. -The means to compare ongoing clinical data with baseline information is provided

A patient reports not feeling well and has a productive cough that is worse at night. The patient is observed to cough violently and produces thick, yellow sputum. Blood pressure is 150/90 mm Hg, heart rate is 92 beats per minute, and respiratory rate is 22 breaths per minute. Wheezing and rhonchi are heard bilaterally. The patient reports chest pain when coughing that radiates to the arm. Which datum would the nurse document as objective data? Select all that apply. One, some, or all responses may be correct.

-Blood pressure -Thick, yellow sputum -Presence of wheezes and rhonchi

The nurse, after administering antibiotics, is updating a patient's chart in the emergency department. Which element of the report does the nurse accurately document to limit nursing liability in case of a legal claim?

-Current medications given -Discontinued medications -Drug allergies

Which information would the nurse include in patient discharge summary forms? Select all that apply. One, some, or all responses may be correct.

-Dietary restrictions -Follow-up care -Emergency contact numbers

Which point would the manager emphasize when teaching nursing staff on the importance of security with the implementation of the electronic health record (EHR)?

-Do not share passwords with anyone. -Do not leave the patient's medical record open unattended on a computer screen. -Do not print information with personal health information (PHI). -Do not log in with someone else's user access

Which outcome is expected after effective documentation?

-Facilitation of proper insurance reimbursement -Efficient use of time -Enhanced continuity of care -Protection for the nurse from legal recourse

The nurse is caring for a patient after knee replacement surgery earlier in the day. Which statement is appropriate to include in the nursing care record?

-Heart rate: 75 beats per minute, urine voided 300 mL, and pain rated as 7 on a scale of 0 to 10. -Temperature: 102° F at 5:00 p.m., Acetaminophen 500 mg at 5:00 p.m., and temperature: 99° F at 6:30 p.m.

Which statement describes the purpose of the incident report?

-Identifies loopholes in the operation of the health care system -Provides good, quality health care -Identifies the need to change a procedure or policy

Which guidance would the nurse provide when teaching students about legal guidelines for documentation?

-Record all facts -Correct all errors promptly. -Chart only for yourself

Which documentation of patient care is appropriate?

-Record pertinent health and drug information. -Record medications that are given and any drug reaction -Document discontinued medication.

A health care provider calls the nursing unit and requests the nurse on duty to update a patient's chart with the physician prescriptions provided. Which action would the nurse perform?

-Record the date and time of the entry. -Record the source of the information and the mode of communication.

Which standardized assessment tool is used for receiving health care funding from the Centers for Medicare and Medicaid Services? Select all that apply. One, some, or all responses may be correct.

-Resident Assessment Instrument (RAI) -Minimum Data Set (MDS

Which characteristic is an advantage of effective documentation?

-Saving time -Minimizing error -Effective continuity of patient care

Which element is integral to the SOAP note? Select all that apply. One, some, or all responses may be correct.

-Subjective -Assessment

Which organization addresses the quality of health care documentation? Select all that apply. One, some, or all responses may be correct.

-The Joint Commission -National Committee for Quality Assurance (NCQA)

The health care provider calls in a prescription for 10 mg of morphine every 4 hours for a patient's postoperative pain. Which action does the nurse take to record and follow the instructions?

-The nurse administers 10 mg of morphine every 4 hours and documents it. -The nurse reads back the prescription to the health care provider for verification and documents that the prescription was read back. -The nurse records the details of the instructions and marks it as a telephone order (TO). -The nurse confirms the patient's name, room number, and diagnosis.

Which statement requires the manager to advise the nurse on the correct techniques of documentation and informatics used in a hand-off report?

-The patient is extremely uncooperative and grumbles all the time -The patient is feeling healthy and refreshed. -The patient, who is 65 years old, is stable with no pain

Which information would the nurse include in a hand-off report at the end of shift?

-The patient's name, age, and admitting diagnosis -Allergies to food and medications -That the patient's pain rating went from an 8 to a 2 on a scale of 1 to 10 after receiving 650 mg of acetaminophen

Which documentation is appropriate after administration of an enema to a patient? Select all that apply. One, some, or all responses may be correct.

-The time the enema is administered -Equipment used for administration

Which is the mode for exchanging information among members of the health care team?

-Written reports -Oral communication

Which system in the electronic health record (EHR) provides warnings to alert a health care provider of patient allergies when prescribing medications?

Clinical decision support system (CDSS)

The nurse interprets the subjective and objective data and diagnoses a problem in a patient. Which step of the nursing process reflects this interpretation, according to SOAPIE (subjective, objective, assessment, plan, intervention, and evaluation) format?

Assessment

Which description is accurate for a system warning alerting the nurse an intervention is inappropriate for a patient because of risk?

Clinical decision support system

Which direction would the manager give to a staff nurse who documented the entry, "The patient is difficult to care for and refuses suggestions for improving appetite?"

Enter only objective and factual information about the patient.

The nurse is given a form with preset standard findings for recording a progress note. The nurse reports the findings in the following way: "Physical Examination: All systems within normal except left lower extremity, casted d/t to heel fracture. Review of Systems: All normal except pain in the left foot." This describes which type of documentation and informatics?

Charting by exception

Which system is involved in providing built-in reminders and alerts for medications and diagnostic tests?

Computerized provider order entry system

How is proper documentation of a patient's health information most useful to medical insurance companies?

Determines the diagnosis-related group (DRG) of the patient

The ability to review patient education provided by other nurses is common in which type of record system?

Electronic health record

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone prescriptions from the provider. Which action requires the new nurse's preceptor to intervene?

Gives a newly prescribed medication before entering the prescription in the patient's medical record

At the end of a shift, the nurse documents a patient's condition, anticipated condition, medications, and nursing interventions fulfilled so that the next nurse can follow the appropriate treatment plan and care for the patient. This describes which type of report?

Hand-off report

Which response by the nurse is accurate for a patient requesting a copy of his or her medical record?

Indicate that he or she has the right to read the record

A health care organization has incorporated information and computer technology. Which system will help the organization comply with the requirements of accrediting agencies?

Nursing clinical information system

Where does the nurse access the information to contact the guardian of a patient?

Patient care summary

Which section of the traditional source record does the nurse use to record patient demographic information?

Patient care summary

Which example of charting a patient's activity is complete?

Patient walked 50 feet and back down hallway with assistance from nurse; heart rate 88 beats per minute and regular before exercise, 94 beats per minute and regular after exercise.

Which response by the student nurse regarding Health Insurance Portability and Accountability Act (HIPAA) regulations needs correction?

Permits health care professionals to print data about the patient's health information and identification for personal use

Which method is appropriate for the nurse to dispose of printed patient information?

Place in a secure canister marked for shredding

In which section would the nurse place subjective and objective data?

Progress notes

How would the nurse respond to a patient who asked the nurse to explain HIPAA?

Provides greater control over personal health care information

Which law is the nurse violating when faxing a patient's medical record to an unknown number?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Which actions require an intervention when reviewing a nursing student's documentation of patient care?

The nursing student documented medication given by another nursing student.

The health care provider prescribes a clear liquid diet for a patient with gastritis. On the first day, the patient consumes soup and tolerates it well. How does the nurse document this finding?

The patient had 2 cups of soup, which was tolerated well.

The nurse assesses a patient on day 3 after surgery and charts a progress note in the SOAP (subjective, objective, assessment, plan) format. Which datum is objective?

The patient's incision site looks clean without purulent drainage or erythema