Fundamentals Potter and Perry Ch 26
What does Focus charting DAR include? (Select all that apply). A) Demographics B) Data C) Alertness Summary D) Action E) Referrals F) Response
B, D, F
What information is tracked on flow sheets? (Select all that apply). A) Physicians name B) Vital signs C) Lab results D) Hygiene (I/O measurements in graphs and flow charts) E) Ambulation activity F) Discharge Plan G) Restraint checks
B, D, E, G
Define Client record: A) A confidential, permanent legal documentation of information relevant to a client's health care. B) Name, address, phone number, insurance information. C) List of medications. D) Temporary notes made pertaining to the clients current visit made on the nurses pocket notepad.
A
Define reports: A) Oral, written, or audiotaped exchanges between caregivers. B) Summary of xrays, MRI and Sonograms done on patient. C) Documentation of all activity patient has had previously for current condition. D) Review of all patients for cause trending.
A
Describe what Critical Pathways are. A) Multidisciplinary care plans that include client problems, key interventions, and expected outcomes. Involves all of health care team for a particular patient. B) Emergency Room proticol C) Critical Care Crash Team D) Steps to take when patient is critical and not expected to survive.
A
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A) "CPOE reduces transcription errors." B) "CPOE reduces the time necessary for health care providers to write orders." C) "Health care providers can write orders from any computer that has Internet access." D) "CPOE reduces the time nurses use to communicate with health care providers."
"CPOE reduces transcription errors."
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? 1. "CPOE reduces transciption errors." 2. "CPOE reduces the time necessary for health care providers to write orders." 3. "Health care providers can write orders from any computer that has Internet access." 4. "CPOE reduces the time nurses use to communicate with health care providers."
1. "CPOE reduces transciption errors." CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly.
You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: 1. Documented medication given by another nursing student 2. Included the date and time of all entries in the chart 3. Stood with his back against the wall while documenting on the computer 4. Signed all documentation electronically
1. Documented medication given by another nursing student Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed.
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) 1. The patient's name, age, and admitting diagnosis 2. Allergies to food and medication 3. Your evaluation that the patient is "needy" 4. How much the patient ate for breakfast 5. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
1. The patient's name, age, and admitting diagnosis 2. Allergies to food and medication 5. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.
On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. The type of feature is most common in what type of record system? 1. Information technology 2. Electronic health record 3. Personal health information 4. Administrative information system
2. Electronic health record This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In this question you are able to access information about the patient from the current hospitalization and from four previous times when the patient accessed care.
A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: 1. Uses SBAR as a format when providing the report 2. Gives a newly ordered medication before entering the order in the patient's medical record 3. Reads the orders back to the health care provider after receiving them and verifies their accuracy 4. Asks the preceptor to listen in on the phone conversation
2. Gives a newly ordered medication before entering the order in the patient's medical record Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.
A patient asks for a copy of her medical record. The best response by the nurse is to: 1. State that only her family may read the record 2. Indicate that she has the right to read her record 3. Tell her that she is not allowed to read her record 4. Explain that only health care workers have access to her record
2. Indicate that she has the right to read her record Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.
While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: 1. The nurses forgot to document on the pulmonary system 2. The nurses were charting by exception 3. The computer is not working correctly 4. The physician does not have authorization to view the nursing assessment
2. The nurses were charting by exception Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.
You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? 1. The new federal laws require that teaching sheets be emailed to patients after they are discharged 2. You need to use words the patients can understand when writing directions 3. The form needs to be given to patients in a sealed envelope to protect their health information 4. The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home
2. You need to use words the patients can understand when writing directions Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ability.
A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at high risk for aspiration because the head of the bed is not elevated high enough. The warning is known as what type of system? 1. Electronic health record 2. Clinical documentation 3. Clinical decision support system 4. Computerized physician order entry
3. Clinical decision support system A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.
You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? 1. HIPAA allows all hospital staff access to your medical record 2. HIPAA limits the information that is documented in your medical record 3. HIPAA provides you with greater control over your personal health care information 4. HIPAA enables health care institutions to release all of your personal information to improve continuity of care
3. HIPAA provides you with greater control over your personal health care information HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record.
What is an appropriate way for a nurse to dispose of printed patient information? 1. Rip several times and place in a standard trash can 2. Place in the patient's paper-based chart 3. Place in a secure canister marked for shredding 4. Burn the documents
3. Place in a secure canister marked for shredding Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times.
A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? 1. Avoid rushing when charting an entry 2. Use correction fluid to remove the entry 3. Draw a single line through the statement and initial it 4. Enter only objective and factual information about the patient
4. Enter only objective and factual information about the patient Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.
Which of the following charting entries is most accurate? 1. Patient walked up and down hallway with assistance, tolerated well 2. Patient up, out of bed, walked down hallway and back to room, tolerated well 3. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during walk 4. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise
4. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise Answer 4 provides the most accurate, objective information for the chart.
As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? 1. The patient has a defiant attitude and is demanding his test results 2. The patient appears to be upset with his nurse because he wants his test results immediately 3. The patient is demanding and complains frequently about his doctor 4. The patient stated that he felt frustrated by the lack of information he received regarding his tests.
4. The patient stated that he felt frustrated by the lack of information he received regarding his tests. Answer 4 is a nonjudgmental statement regarding the nurse's observations about the patient. Answers 1 and 3 are judgmental, and information in the medical record should be factual and nonjudgmental. Answer 2 needs to be more specific regarding the reason for the patient's concern.
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A) "CPOE reduces transcription errors." B) "CPOE reduces the time necessary for health care providers to write orders." C) "Health care providers can write orders from any computer that has Internet access." D) "CPOE reduces the time nurses use to communicate with health care providers."
A
Documentation is: A) Anything written or printed that you rely on as record or proof for authorized persons. B) Lab results for a patient you are taking care of. C) Admission paperwork for billing purposes. D) Instructions from the attending doctor.
A
What does being "Complete" mean? A) Documentation containing appropriate and essential information B) A list of patients food likes and dislikes. C) A full narrative of how the patient was cared for.
A
What is Auditing? A) Objective, ongoing review of records to determine the degree to which quality improvement standards are met. B) Investigation by TJC for fraud C) Employee performance evaluations D) Research on "Never Events".
A
What is a Kardex? A) Has activity, treatment, nursing care plan sections that organize information for quick reference. Older method, not used so much any more. B) A medication for the lips. C) Roledex of contact information for Physicians and other healthcare professionals. D) Charts kept at the end of the patients bed that provides all of their medical information.
A
What is research? A) Gathering of statistical data of clinical disorders, complications, therapies, recovery and deaths B) Studies by nurses who are back in school for their masters degree. C) Scientific study of a specific illness conducted by scientists and doctors to create new medications.
A
You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A) Documented medication given by another nursing student. B) Included the date and time of all entries in the chart. C) Stood with his back against the wall while documenting on the computer. D) Signed all documentation electronically.
A
List the information that needs to be documented with telephone reports. (Select all that apply). A) Date & TIme of call B) Diagnosis C) Physicans name D) Who was called E) Why they were called (info they were given and info that was received from them)
A, D, E
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications C) Your evaluation that the patient is "needy" D) How much the patient ate for breakfast E) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications E) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications C) Your evaluation that the patient is "needy" D) How much the patient ate for breakfast E) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
A, B, E
What information should be included in a transfer report? (Select all that apply) A) Client's name B) Age C) Marital Status D) Employer E) Primary physician F) Medical diagnosis G) Summary of progress H) Current health status I) Insurance J) Allergies K) Need for additional equipment
A, B, E, F, G, H, J, K
PIE--nursing based charting. (Select all that apply). A) Problem B) Assessment C) Intervention D) Evaluation E) Expectations
A, C, D
Which of the following are examples of events that would be recorded by an incident or occurrence report? (Select all that apply). A) Patient fall B) MRI machine not working C) Needle stick D) Medication error E) Ambulance arrival in the ER
A, C, D
List major areas to include in a change of shift report. (Select all that apply). A) Date & Time. B) Census count C) Essential background information. D) Client's nursing diagnosis or health care problems and their related causes. E) Length of time you have cared for patient. F) Description of objective measurements or observations G) Significant information about family members. H) Discharge plan. I) List of patients belongings. J) Significant changes in the way therapies are to be given. K) Any patient education completed. L) Evaluation of nursing care to date M) Priorities
A, C, D, F, G, H, J, K, L, M
SOAP--medical records based includes what type of information? A) Subjective B) Organized C) Objective D) Analytical E) Assessment F) Plan
A, C, E, F
A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B) Gives a newly ordered medication before entering the order in the patient's medical record. C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. D) Asks the preceptor to listen in on the phone conversation.
B
Problem oriented medical record (POMR) includes what information? A) Demographics B) Database C) Pain level D) Problem List E) Care Plan F) Discharge Plan G) Progress notes H) Referrals
B, D, E, G
A patient asks for a copy of her medical record. The best response by the nurse is to: A) State that only her family may read the record. B) Indicate that she has the right to read her record. C) Tell her that she is not allowed to read her record. D) Explain that only health care workers have access to her record.
B
Define Referrals: A) A physicians order for lab work B) An arrangement for services by another care provider C) Any physicians order that requires a authorization from the insurance company. D) Treatment options the physician discusses with the patient.
B
During a change-of-shift report: A) Two or more nurses always visit all patients to review their plan of care. B) The nurse should identify nursing diagnoses and clarify patient priorities. C) Nurses should exchange judgments they have made about patient attitudes. D) Patient information is communicated from a nurse on a sending unit to a nurse on a receiving unit.
B
Explain what "Current" means. A) The direction the patient is laying when they are on a bed. B) Timely entries; immediate documentation of information as it is collected from the client. C) Patient's ability to tell you the date and time. D) Patient's health history as it relates to their recent issues.
B
How is Charting by exception different than other charting methods? A) It focuses on only one diagnosis. B) Focuses on deviation from the established norm or abnormal findings, highlights trends or changes. If no new notes, then no new changes or findings. If nothing is there, it doesn't mean the nurse forgot it, it means there's nothing new. C) Charting done for patients who are in critical care and have multiple healthcare issues.
B
On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A) Information technology. B) Electronic health record. C) Personal health information. D) Administrative information system.
B
What are standardized care plans? A) Computer generated care plans based on patients age, weight, and height. B) Preprinted, set guidelines used to care for the client. C) Care plans dictated by TJC. D) Plans of care that work 100% of the time and require no deviation ever.
B
What does it meant to be accurate? A) Only having to check the vitals one time during a shift. B) The use of accepted abbreviations, symbols, and system of measures that are clear and easy to understand C) The weight of a patient in ounces. D) Spelling things correctly when writing notes.
B
While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A) The nurses forgot to document on the pulmonary system. B) The nurses were charting by exception. C) The computer is not working correctly. D) The physician does not have authorization to view the nursing assessment.
B
You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B) You need to use words the patients can understand when writing the directions. C) The form needs to be given to patients in a sealed envelope to protect their health information. D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.
B
Explain the new rights for clients related to HIPPA. A) Patient right to leave healthcare facility. B) Patient education on privacy protections C) Patient's right to access their medical records. D) Provider must receive consent from patient before releasing information. E) Recourse options if privacy protections are violated.
B, C, D, E
What are the guidelines for quality documentation and reporting? (Select all that apply) A) Detailed B) Factual C) Organized D) Focused E) Accurate F) Complete G) Current H) Electronically recorded
B, C, E, F, G
What are the guidelines the nurse should follow when receiving a telephone order? (Select all that apply) A) Date & time of follow-up visit B) Clien'ts name C) Room # (if applicable) D) Insurance information E) Diagnosis F) Repeat & clarify orders with physician G) Write TO or VO to indicat taken by phone H) Date & Time order taken I) Physicians name J) Physician must sign order within timeframe required by institution (usually 24-48 hours).
B, C, E, F, G, H, I, J
SOAPIE is the SOAP meathod with what two additional steps? A) Individual care plan B) Intervention C) Expectations D) Evaluation
B, D
A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A) Electronic health record B) Clinical documentation C) Clinical decision support system D) Computerized physician order entry
C
Accreditation is: A) Certification by the ANA. B) Medicare approval. C) Joint Commission specifies guidelines for documentation. D) Passing the NCLEX.
C
An incident report is: A) A legal claim against a nurse for negligent nursing care. B) A summary report of all falls occurring on a nursing unit. C) A report of an event inconsistent with the routine care of a patient. D) A report of a nurse's behavior submitted to the hospital administration.
C
Case Management documenting is: A) Referral of patient to another provider. B) Interaction with Social Services to support patients needs away from healthcare facility. C) Incorporates a multidisciplinary approach to documenting care. D) Involvement of Qualtiy Assurance in the care of patients.
C
Define "Education". A) Nursing giving a patient a pamplet about various health conditions. B) Smoking cessation classes C) Learning the nature of an illness and the individual client's responses D) Nursing care in local schools with school aged children.
C
Define consultations: A) Lab results B) End of shift transition to next shift C) Form of discussion whereby one professional caregiver gives formal advice about the level of care of a client to another caregiver. D) Indication by billing on patients ability to pay.
C
What does it meant to be organized with documentation? A) Have everything in one folder so it can be found. B) Color code information from various departments to make it easier to identify that information. C) Communicate information in a logical order. D) Write legibily.
C
What does the admission nursing history form provide? A) Insurance B) DPOA information C) Baseline data to compare with changes in the clients condition. D) Risk factors
C
What is an appropriate way for a nurse to dispose of printed patient information? A) Rip several times and place in a standard trash can B) Place in the patient's paper-based chart C) Place in a secure canister marked for shredding D) Burn the documents
C
You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A) HIPAA allows all hospital staff access to your medical record. B) HIPAA limits the information that is documented in your medical record. C) HIPAA provides you with greater control over your personal health care information. D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.
C
If an error is made while recording, the nurse should: A) Erase it or scratch it out. B) Leave a blank space in the note. C) Draw a single line through the error and initial it. D) Obtain a new nurse's note and rewrite the entries.
C.
A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A) Electronic health record B) Clinical documentation C) Clinical decision support system D) Computerized physician order entry
Clinical decision support system
A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A) Avoid rushing when charting an entry. B) Use correction fluid to remove the entry. C) Draw a single line through the statement and initial it. D) Enter only objective and factual information about the patient.
D
As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A) The patient has a defiant attitude and is demanding his test results. B) The patient appears to be upset with his nurse because he wants his test results immediately. C) The patient is demanding and complains frequently about his doctor. D) The patient stated that he felt frustrated by the lack of information he received regarding his tests.
D
Discharge summary forms tell you what? A) Diagnosis of patient B) Total charges of visit C) Allergies D) Emphasize previous learning by the client and the care that should be continued.
D
Source record charting provides what? A) Reference information on where to find all resources. B) Key Code to help decifer physician notes C) Information of the source or cause of the patients illness. D) Separate section for each discipline
D
The primary purpose of a patient's medical record is to: A) Provide validation for hospital charges. B) Satisfy requirements of accreditation agencies. C) Provide the nurse with a defense against malpractice. D) Communication accurate, timely information about the patient.
D
The standards of documentation by the Joint Commission require: A) Narrative on how patient was cared for. B) Patient's vital signs every 4 hours. C) A resolution date for all planned outcomes. D) Documentation within the context of the nursing process, as well as evidence of client and family teaching and discharge planning.
D
What are Acuity records used for? A) Helps billing determine what to charge for a type of service. B) Sharpness; acuteness; keenness of patient C) The global standard for payment efficiency D) Records that assist a nurse manager in planning staffing requirements for the future.
D
What does "Factual" mean? A) Giving the patients point of view to understand how they feel. B) Your opion of the patients condition or behavior. C) Emotional and psychological assessment of the patient. D) Descriptive, objective information about what a nurse sees, hears, feels, and smells.
D
Which of the following charting entries is most accurate? A) Patient walked up and down hallway with assistance, tolerated well. B) Patient up, out of bed, walked down hallway and back to room, tolerated well. C) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
D
Which of the following is correctly charted according to the six guidelines for quality recording? A) "Was depressed today." B) "Respirations rapid; lung sounds clear." C) "Had a good day. Up and about in room." D) "Crying. States she doesn't want visitors to see her like this."
D
You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A) Documented medication given by another nursing student. B) Included the date and time of all entries in the chart. C) Stood with his back against the wall while documenting on the computer. D) Signed all documentation electronically.
Documented medication given by another nursing student.
On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A) Information technology. B) Electronic health record. C) Personal health information. D) Administrative information system.
Electronic health record.
A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A) Avoid rushing when charting an entry. B) Use correction fluid to remove the entry. C) Draw a single line through the statement and initial it. D) Enter only objective and factual information about the patient.
Enter only objective and factual information about the patient.
A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B) Gives a newly ordered medication before entering the order in the patient's medical record. C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. D) Asks the preceptor to listen in on the phone conversation.
Gives a newly ordered medication before entering the order in the patient's medical record.
You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A) HIPAA allows all hospital staff access to your medical record. B) HIPAA limits the information that is documented in your medical record. C) HIPAA provides you with greater control over your personal health care information. D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.
HIPAA provides you with greater control over your personal health care information.
A patient asks for a copy of her medical record. The best response by the nurse is to: A) State that only her family may read the record. B) Indicate that she has the right to read her record. C) Tell her that she is not allowed to read her record. D) Explain that only health care workers have access to her record.
Indicate that she has the right to read her record.
Which of the following charting entries is most accurate? A) Patient walked up and down hallway with assistance, tolerated well. B) Patient up, out of bed, walked down hallway and back to room, tolerated well. C) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
What is an appropriate way for a nurse to dispose of printed patient information? A) Rip several times and place in a standard trash can B) Place in the patient's paper-based chart C) Place in a secure canister marked for shredding D) Burn the documents
Place in a secure canister marked for shredding
Match the correct entry with the appropriate SOAP category. a. Repositioned patient on right side. Encouraged patient to use patient controlled analgesia (PCA) device. b. "The pain increases every time I try to turn on my left side." c. Acute pain related to tissue injury from surgical incision d. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation
S - b. "The pain increases every time I try to turn on my left side." O - d. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation A - c. Acute pain related to tissue injury from surgical incision P - a. Repositioned patient on right side. Encouraged patient to use patient controlled analgesia (PCA) device.
While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A) The nurses forgot to document on the pulmonary system. B) The nurses were charting by exception. C) The computer is not working correctly. D) The physician does not have authorization to view the nursing assessment.
The nurses were charting by exception.
As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A) The patient has a defiant attitude and is demanding his test results. B) The patient appears to be upset with his nurse because he wants his test results immediately. C) The patient is demanding and complains frequently about his doctor. D) The patient stated that he felt frustrated by the lack of information he received regarding his tests.
The patient stated that he felt frustrated by the lack of information he received regarding his tests.
You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B) You need to use words the patients can understand when writing the directions. C) The form needs to be given to patients in a sealed envelope to protect their health information. D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.
You need to use words the patients can understand when writing the directions.
