Medical, Pharmaceutical & Health Sciences
NursingFundamentals NursingNursing Active LearningPractice Set 6
NursingFundamentals NursingNursing Active LearningPractice Set 6Documentation, Electronic Health Records, And Reporting
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Questions Bank
- Nursing, Theory, and Professional PracticeValues, Beliefs, and CaringCommunicationCritical Thinking in NursingIntroduction to the Nursing ProcessAssessmentNursing DiagnosisPlanningImplementation and EvaluationDocumentation, Electronic Health Records, and ReportingEthical and Legal ConsiderationsLeadership and ManagementEvidence-Based Practice and Nursing ResearchHealth Literacy and Patient EducationNursing InformaticsHealth and WellnessHuman Development: Conception through AdolescenceHuman Development Young Adult to Older AdultVital SignsHealth History and Physical AssessmentEthnicity and Cultural AssessmentSpiritual HealthPublic Health, Community Base, and Home Health CareHuman SexualitySafetyAsepsis and Infection ControlHygiene and Personal CareActivity, Immobility, and Safe MovementSkin Integrity and Wound CareNutritionCognitive and Sensory AlterationsStress and CopingSleepDiagnostic TestingMedication AdministrationPain ManagementPerioperative Nursing CareOxygenation and Tissue PerfusionFluid, Electrolytes, and Acid-Base BalanceBowel EliminationUrinary EliminationDeath and Loss
Question 1
Free
Multiple Choice
Accurate documentation by the nurse is necessary since proper documentation:
Choose correct answer/s
is needed for proper reimbursement.
must be electronically generated.
does not involve e-mails or faxes.
is only legal if written by hand.
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Question 2
Free
Multiple Choice
Which of the following is true regarding nursing documentation?
Choose correct answer/s
Standards for documentation are established by a national commission.
Medical records should be accessible to everyone.
Documentation should not include the patient's diagnosis.
High-quality nursing documentation reflects the nursing process.
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Question 3
Free
Multiple Choice
The medical record:
Choose correct answer/s
serves as a major communication tool but is not a legal document.
cannot be used to assess quality of care issues.
is not used to determine reimbursement claims.
can be used as a tool for biomedical research and provide education.
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Question 4
Free
Multiple Choice
Paper records are being replaced by other forms of record keeping because:
Choose correct answer/s
paper is fragile and susceptible to damage.
paper records are always available to multiple people at a time.
paper records can be stored without difficulty and are easily retrievable.
paper records are permanent and last indefinitely.
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Question 5
Free
Multiple Choice
The nurse is charting in the paper medical record. She should:
Choose correct answer/s
print his/her name since signatures are often not readable.
not document her credentials since everyone knows that she is a nurse.
skip a line, leaving a blank space, between entries so that it looks neater.
use black ink unless the facility allows a different color.
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Question 6
Multiple Choice
The nurse is admitting a patient who has had several previous admissions. In order to obtain a knowledge base about the patient's medical history, the nurse may use the:
Choose correct answer/s
electronic medical record (EMR).
the computerized provider order entry (CPOE).
electronic health record (EHR).
American Recovery and Reinvestment Act.
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Question 7
Multiple Choice
The use of electronic health records:
Choose correct answer/s
improves patient health status.
requires a keyboard to enter data.
has not been shown to reduce medication errors.
requires increased storage space.
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Question 8
Multiple Choice
The nurse is caring for patients on unit that uses electronic health records (EHRs). In order to protect personal health information, the nurse should:
Choose correct answer/s
allow only nurses that she knows and trusts to use her verification code.
not worry about mistakes since the information cannot be tracked.
never share her password with anyone.
be aware that the EHR is sophisticated and immune to failure.
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Question 9
Multiple Choice
Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:
Choose correct answer/s
documents facts.
documents how he/she feels about the care being provided.
documents in a "block" fashion once per shift.
double documents as often as possible in order to not miss anything.
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Question 10
Multiple Choice
Nursing documentation is guided by:
Choose correct answer/s
the Nursing process
the North American Nursing Diagnosis Association (NANDA) diagnoses.
Nursing Interventions Classification.
Nursing Outcomes Classification
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Question 11
Multiple Choice
PIE, APIE, SOAP, and SOAPIE are:
Choose correct answer/s
chronologic.
examples of problem-oriented charting.
narrative charting.
forms of "charting by exception."
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Question 12
Multiple Choice
A type of charting that records only abnormal or significant data is:
Choose correct answer/s
PIE.
SOAP.
narrative.
charting by exception.
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Question 13
Multiple Choice
The nurse is preparing to administer medications to the patient. Prior to doing so, she/he compares the provider orders with the:
Choose correct answer/s
flow sheet
Kardex
MAR
admission summary
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Question 14
Multiple Choice
The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. The best central location to obtain this information is the:
Choose correct answer/s
admission summary.
discharge summary.
flow sheet.
Kardex.
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Question 15
Multiple Choice
The nurse is charting using paper nursing notes. The nurse is aware that:
Choose correct answer/s
attorneys are not allowed access to medical records during litigation.
when mistakes are made in documentation, the nurse should scribble out the entry.
only one nurse should document on a sheet so that it can be removed in case of error.
the medical record is the most reliable source of information in any legal action.
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Question 16
Multiple Choice
The nurse is charting using electronic documentation. With electronic documentation:
Choose correct answer/s
errors can be corrected and totally removed from the record in the screen view.
log-on access to the electronic record identifies the person charting.
each entry requires the nurse to sign her/his name and credentials.
documenting significant changes in the electronic record ends the nurse's responsibility.
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Question 17
Multiple Choice
How should the nurse correct an error in charting?
Choose correct answer/s
remove the sheet with the error and replace it with a new sheet with the correct entry.
scribble out the error and rewrite the entry correctly.
draw a single line through the error, and then write "error" above or after the entry
leave the entry as is and tell the charge nurse.
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Question 18
Multiple Choice
If a verbal or phone order is necessary in an emergency, the order:
Choose correct answer/s
must be taken by an RN or LPN.
must be repeated verbatim to confirm accuracy.
documented as a written order.
does not need further verification by the provider.
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Question 19
Multiple Choice
The process of making a change-of-shift report (handoff):
Choose correct answer/s
is an uncommon occurrence of little importance.
occurs only at change of shift and only to oncoming nurses.
can lead to patient death if done incorrectly.
does not allow for collaboration or problem solving.
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Question 20
Multiple Choice
The patient has fallen when trying to climb out of bed. The nurse:
Choose correct answer/s
needs to complete an incident report as a risk management document.
completes an incident report since it is a permanent part of the medical record.
must document that an incident report was completed in the medical record.
should say nothing about the incident in the medical record.
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