Ch 26 Nclex - Documentation & Informatics

Question 1

1. A manager is reviewing the nursing documentation entered by a staff nurse in a patient’s electronic medical record and finds the following entry, “Patient is difficult to care for, refuses suggestion for improving appetite.” Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information?
2. “Avoid rushing when documenting an entry in the medical record.”
3. “Use correction fluid to remove the entry.”
4. “Draw a single line through the statement and initial it.”
5. Enter only objective and factual information about a patient in the medical record.

Answer 1

4

Question 2

2. A preceptor observes a new graduate nurse discussing changes in a patient’s condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse:
3. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone.
4. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record.
5. Gives a newly ordered medication before entering the order in the patient’s medical record.
6. Asks the preceptor to listen in on the phone conversation.

Answer 2

3

Question 3

3. As the nurse enters a patient’s room, the nurse notices that the patient is anxious. The patient 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 way for the nurse to document this observation of the patient?
4. “The patient has a defiant attitude and is demanding test results.”
5. “The patient appears to be upset with the nurse because he wants his test results immediately.”
6. “The patient is demanding and is complaining about the doctor.”
7. “The patient stated feelings of frustration from the lack of information received regarding test results.”

Answer 3

4

Question 4

4. The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, “I’m not familiar with these HIPAA regulations. How will they affect my care?” Which of the following is the best response?
5. HIPAA allows all hospital staff access to your medical record.
6. HIPAA limits the information that is documented in your medical record.
7. HIPAA provides you with greater protection of your personal health information.
8. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

Answer 4

3

Question 5

5. A patient states, “I would like to see what is written in my medical record.” What is the nurse’s best response?
6. “Only your family can read your medical record.”
7. “You have the right to read your record.”
8. “Patients are not allowed to read their records.”
9. “Only health care workers have access to patient records.”

Answer 5

2

Question 6

6. Which of the following documentation entries is most accurate?
7. “Patient walked up and down hallway with assistance, tolerated well.”
8. “Patient up, out of bed, walked down hallway and back to room, tolerated well.”
9. “Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk.”
10. “Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise.”

Answer 6

4

Question 7

7. Label each line of documentation with the appropriate SOAP category (Subjective [S], Objective [O], Assessment [A], Plan [P]).
8. ______ Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device.
9. ______ “The pain increases every time I try to turn on my left side.”
10. ______ Acute pain related to tissue injury from surgical incision.
11. ______ Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

Answer 7

1=P, 2=S, 3=A, 4=O

Question 8

8. Fill in the Blank. While working on a unit within a hospital, the nurse was able to access a patient’s medical record and review the education that other nurses provided during an initial hospitalization and three subsequent clinic visits that occurred in different provider’s offices over the past 6 months. This type of feature is most common in a(n) __________________________.

Answer 8

Electronic health record

Question 9

9. The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? (Select all that apply.)
10. The patient’s name, age, and admitting diagnoses
11. The discussion of any allergies to food and medications that the patient has
12. That the nurse receiving the report was advised that the patient is “needy” and “on the call light all the time”
13. That the patient’s pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650mg of Tylenol
14. Description of any unresolved problems and current interventions in place

Answer 9

1,2,4,5

Question 10

10. The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (Select all that apply.)
11. Documents a medication given by another nursing student.
12. Includes the date and time of the entry into the medical record.
13. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient’s room.
14. Leaves a slip of paper with her user name and password in the patient’s room.
15. Starts to enter “Docusate sodium 100mg ordered at 08:00 held. Patient declined to take dose stating, “I had several loose stools yesterday, and I’m afraid if I take this dose the problem will get worse,” as a narrative comment.

Answer 10

1,4

Question 11

11. 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?
12. “CPOE reduces transcription errors.”
13. “CPOE reduces the time needed for health care providers to write orders.”
14. “CPOE eliminates verbal and telephone orders from health care providers.”
15. “CPOE reduces the time nurses use to communicate with health care providers.”

Answer 11

1

Question 12

12. The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2mg intravenously (IV) for pain at 3:45 PM, changed the dressing over the patient’s abdominal incision at 5:34 PM, and administered Ancef 1g IV at 8:00 PM. Using correct military time, label the documentation for each task with the time that it was completed.
13. ______ Morphine 2mg IV given for pain rating of 8/10
14. ______ Dressing changed over midline abdominal incision using aseptic technique
15. ______ Ancef 1g given IVPB over 30 minutes.

Answer 12

1=15:45, 2=17:34, 3=20:00

Question 13

13. The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45mL per hour. The nurse enters the patient assessment data and information that the head of the patient’s bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system?
14. Electronic health record
15. Clinical documentation
16. Clinical decision support system
17. Computerized physician order entry

Answer 13

3

Question 14

14. While reviewing the pulmonary assessment entered by a nurse in a patient’s electronic medical record (EMR), a physician notices that the only information documented in that section is “WDL” (within defined limits). The physician also is not able to find a narrative description of the patient’s respiratory status in the nurse’s progress notes. What is the most likely reason for this?
15. The nurse caring for the patient forgot to document on the pulmonary system.
16. The EMR uses a charting-by-exception format.
17. The computer shut down unexpectedly when the nurse was documenting the assessment.
18. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

Answer 14

2

Question 15

15. What is the appropriate way for a nurse to dispose of information printed out from a patient’s electronic health record?
16. Rip the papers up into small pieces and place the pieces into a standard trash can
17. Place all papers in the flip-top binder designated for that patient that is located in the nurse’s station on the patient care unit
18. Place papers with patient information in a secure canister marked for shredding
19. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

Answer 15

3