CMI Chapter 19 Documenting, reporting, conferring, and using informatics NLCEX questions
A nurse helps a patient who has cystic fibrosis prepare a standalone personal health record. Which statement by the nurse best explains this type of information?
"You can fill in information from your own records and store it on your computer or the Internet."
A nurse takes a patient's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?
Graphic Sheets
A nurse is documenting the effectiveness of a client's pain management on the client record. Which documentation is written correctly?
Mr. Gray reports that on a scale of 0 to 10, the pain he is experiencing is a 3.
A nurse documents the following patient data in the patient record according to the SOAP format: Patient complains of unrelieved pain; patient is seen clutching his side and grimacing; patient pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?
Problem-oriented method
A nurse is arranging for home care for patients and reviews the Medicare reimbursement requirements. Which patient meets one of these requirements?
a patient who is homebound and needs skilled nursing care
A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format?
charting by exception
A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?
telemedicine and mobile technology
Which nursing action is an example of properly handling the patient record?
the nurse allows the patient to see and copy her own health record
A patient accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?
Accurately documenting patient care on the patient record!
The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?
The nurse meets with nurses or other health care professionals to discuss some aspect of patient care.