Documentation And Informatics

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Question 1
Free
Multiple Choice

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?

Choose correct answer/s
A

The student nurse reads the patient's plan of care.

B

The student nurse reviews the patient's medical record.

C

The student nurse shares patient information with a friend.

D

The student nurse documents medication administered to the patient.

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Question 2
Free
Multiple Choice

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete?

Choose correct answer/s
A

A verbal report

B

An electronic record entry

C

A referral

D

An acuity rating

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Question 3
Free
Multiple Choice

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?

Choose correct answer/s
A

Determining the degree to which standards of care are met by reviewing patients' health records

B

Realizing that care not documented in patients' health records still qualifies as care provided

C

Basing reimbursement upon the diagnosis-related groups documented in patients' records

D

Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment

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Question 4
Free
Multiple Choice

After providing care, a nurse charts in the patient's record. Which entry will the nurse document?

Choose correct answer/s
A

Appears restless when sitting in the chair

B

Drank adequate amounts of water

C

Apparently is asleep with eyes closed

D

Skin pale and cool

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Question 5
Free
Multiple Choice

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?

Choose correct answer/s
A

Status unchanged, doing well

B

Patient seems to be in pain and states, "I feel uncomfortable."

C

Left knee incision 1 inch in length without redness, drainage, or edema

D

Patient is hard to care for and refuses all treatments and medications. Family is present.

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Question 6
Multiple Choice

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up?

Choose correct answer/s
A
The new nurse documents only for self.
B
The new nurse charts consecutively on every other line.
C
The new nurse ends each entry with signature and title.
D
The new nurse keeps the password secure.
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Question 7
Multiple Choice

A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally?

Choose correct answer/s
A
Charts legibly
B
States the patient is belligerent
C
Writes entry for another nurse
D
Uses correction fluid to correct error
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Question 8
Multiple Choice

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse find?

Choose correct answer/s
A
Electronic medical record
B
Electronic health record
C
Electronic charting record
D
Electronic problem record
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Question 9
Multiple Choice

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting?

Choose correct answer/s
A
Patient went up and down stairs
B
Demonstrated use of crutches
C
Used crutches with no difficulties
D
Deficient knowledge related to never using crutches
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Question 10
Multiple Choice

A nurse wants to find the daily weights of a patient. Which form will the nurse use?

Choose correct answer/s
A
Database
B
Progress notes
C
Patient care summary
D
Graphic record and flow sheet
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Question 11
Multiple Choice

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?

Choose correct answer/s
A
Add this data to the problem list.
B
Focus chart using the DAR format.
C
Document the variance in the patient's record.
D
Report a positive variance in the next interdisciplinary team meeting.
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Question 12
Multiple Choice

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?

Choose correct answer/s
A
Upon admission
B
Right before discharge
C
After the congestion is treated
D
When the primary care provider writes the order
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Question 13
Multiple Choice

A patient is being discharged home. Which information should the nurse include?

Choose correct answer/s
A
Acuity level
B
Community resources
C
Standardized care plan
D
Signature for verbal order
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Question 14
Multiple Choice

A nurse developed the following discharge summary sheet. Which critical information should the nurse add? image

Choose correct answer/s
A
Clinical decision support system
B
Admission nursing history
C
Mode of transportation
D
SOAP notes
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Question 15
Multiple Choice

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record?

Choose correct answer/s
A
Nursing process form
B
Step-by-step skills manual
C
A list of possible procedures
D
Reports to third-party payers
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Question 16
Multiple Choice

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?

Choose correct answer/s
A
A minimum data set
B
An admission assessment and acuity level
C
A focused assessment/specific body system
D
An intake assessment form and auditing phase
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Question 17
Multiple Choice

A nurse is charting. Which information is critical for the nurse to document?

Choose correct answer/s
A
The patient had a good day with no complaints.
B
The family is demanding and argumentative.
C
The patient received a pain medication, Lortab.
D
The family is poor and had to go on welfare.
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Question 18
Multiple Choice

A nurse is completing an OASIS data set on a patient. The nurse works in which area?

Choose correct answer/s
A
Home health
B
Intensive care unit
C
Skilled nursing facility
D
Long-term care facility
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Question 19
Multiple Choice

A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include?

Choose correct answer/s
A
The family is a "pain."
B
Pupils equal and reactive to light
C
Had poor results from the pain medication
D
Sharp pain of 8 on a scale of 1 to 10
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Question 20
Multiple Choice

A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order?

Choose correct answer/s
A
As the nurse and health care provider leave a patient's room, the primary care provider gives the nurse an order.
B
At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.
C
At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order.
D
A nurse reads an order correctly as written by the health care provider in the patient's medical record.
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