1125 PrepU Informatics/Health Information Technology
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."
Nurse A is having difficulty logging into the automated medication-dispensing system, and asks Nurse B to log in momentarily so that Nurse A is not delayed in administering client medications. What is Nurse B's appropriate response?
"I will get the hospital's information system's phone number for you."
A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse?
"Legal policy requires nursing practice to be permanently integrated into the client record." Computer applications and electronic health record formats may have some differences, but they all use an integrated record. Suggesting that the nurse develop a new tool would be inappropriate, as separate nursing documentation would not be legal.
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."
An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? Select all that apply.
-"Using the system is highly intuitive." -"We've noticed that this system really helps to save us valuable time." -"This system fits nicely into how we work."
Which are appropriate actions for protecting clients' identities? Select all that apply.
-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.
The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply.
-The nurse asks questions about the child's history. -The nurse finds out the reason for the child's visit to the health care setting. -The nurse interviews the child's caregiver.
Which statements are true about informatics in nursing practice? Select all that apply.
-Utilization of information services helps to support decision making. -Nurses should value technologies that support error prevention and care coordination. -The use of informatics can help manage knowledge and mitigate error.
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.
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.
A healthcare provider writes a prescription for "digoxin .125mg PO once daily" and "nitroglycerin patch 0.4 mg/hour topically to be worn 0800-2000 daily." What does the nurse clarify with the healthcare provider?
the dose of the digoxin
A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?
those directly involved in the client's care
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 she 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
Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant. This is her 4th pregnancy. She gave birth to one baby vaginally at 26 weeks who died, experienced a miscarriage, and has one living child who was delivered at 38 weeks gestation.
4, 1, 1, 1, 1
An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next?
Analyze and Plan
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 describing the framework underlying informatics practice. Which component of the framework would the nurse specialist describe as discrete entities without interpretation?
Data
An informatics nurse is participating in an online continuing education course about nursing informatics. The nurse demonstrates successful comprehension of the course by identifying which individual as being considered the first informatics nurse?
Florence Nightingale
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 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.
A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first?
Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed.
The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes?
Suggest to the nurse manager that an in-service on abbreviation use would be helpful.
A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response?
Tactfully request the provider to input the order into the computerized provider order system.
Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?
The nurse locks out client information, except to those who have been authorized through appropriate security measures.
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.
A informatics nurse is involved in testing a new clinical information system at the clinic. Place the phases of testing that would occur from first to last.
Unit Function Integration Performance User acceptance
An informatics nurse specialist is engaged in evaluating a clinical information system. At which time would the nurse specialist anticipate the need to obtain help from a statistician?
When determining the data collection method
A female client is having a procedure this morning that involves radiologic examination of the fallopian tubes using a radiopaque medium. What procedure should the nurse document as being performed?
a hysterosalpingography a radiologic examination of the fallopian tubes using a radiopaque medium
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
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
The nurse managers of a home healthcare 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
In many institutions, which telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner?
orders for antibiotics Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours.
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
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? Select all that apply.
-Greater client engagement -Improvement in health care quality -Reduction in privacy breaches of client information
The nurse started a peripheral intravenous line in a client's left forearm. What should the nurse include in the documentation? Select all that apply.
-location where intravenous access placed -size of the intravenous catheter -date intravenous catheter placed -condition of the site
A facility plans to implement a new electronic medication documentation system. An informatics nurse specialist conducts a focus group with staff nurses to gather information. The nurse specialist asks the group about the current system being used, including a step-by-step account of the actions they perform. The nurse specialist also asks the nurses how they see this new system affecting this process and their overall daily tasks. The informatics nurse specialist is demonstrating which ANA informatics competency?
Assessment
