Chapter 03: Documentation and Informatics

Question 1

The nurse discovers a medication error on another nurse’s documentation, so the nurse
completes an incident report. Which statement should the nurse include in the report?
a. “Nurse mistakenly gave the wrong dose of medication for pain.”
b. “Nurse gave incorrect dose of pain medication, but patient is all right.”
c. “Morphine 10 mg IM given rather than morphine 5 mg IM as ordered.”
d. “Physician will be notified of error when he makes rounds tomorrow.”

Answer 1

c. “Morphine 10 mg IM given rather than morphine 5 mg IM as ordered.”

Question 2

The nurse is documenting the care of a patient. Which entry would be characteristic of
charting by exception (CBE) as a documentation method?
a. The patient needed to be turned every hour because of increasing pain.
b. The patient’s vital signs are stable.
c. The patient’s gait was steady with assistance from physical therapy.
d. There was no odor when the dressing was removed.

Answer 2

a. The patient needed to be turned every hour because of increasing pain

Question 3

The nurse is documenting on a patient with a respiratory problem. Which patient datum
documented by the nurse is the least objective?
a. Cool and dusky skin
b. Low flow rate oxygen
c. 30 breaths per minute
d. Very restless and drowsy

Answer 3

b. Low flow rate oxygen

Question 4

The nurse runs into a co-worker whose family friend is a patient on the unit. The co-worker
asks about the friend’s health problems. Which is the correct response by the nurse?
a. “Your friend told us to say nothing.”
b. “Why don’t you ask your friend now?”
c. “You know I can’t talk about the patients.”
d. “Well, it was really a very difficult surgery.”

Answer 4

c. “You know I can’t talk about the patients.”

Question 5

The nurse is providing home care for a patient with an infection that is not improving. The
patient refuses to see an infectious disease specialist. What should the nurse include in the
documentation of the patient teaching provided?
a. The discussion about the consequences of refusing to see a specialist and the
patient’s response.
b. The explanation that avoiding the specialist will most likely lead to a worse
outcome.
c. A hopeful explanation that this will most likely be the last medical specialist that
the patient will need to see.
d. The recommendation that the patient should discuss the decision with the family.

Answer 5

a. The discussion about the consequences of refusing to see a specialist and the
patient’s response.

Question 6

At 0915 the nurse repeatedly instructs the patient to remain in bed. At 0930 the nurse enters
the patient’s room, finds the patient on the floor, and hears the patient say, “I need pain
medicine.” Which should the nurse do to document this event?
a. Label the late entry using the time of 9:15 AM.
b. Enclose the patient statement within quotations.
c. Document completion of an incident report.
d. Record plan to administer pain medication.

Answer 6

b. Enclose the patient statement within quotations.

Question 7

A nurse passes by a computer screen that has patient information that can be seen by visitors.
What is the appropriate action for the nurse to take at this time?
a. Leave the computer screen alone.
b. Try to find the nurse caring for this patient.
c. Document this situation on an incident report.
d. Close the computer screen.

Answer 7

d. Close the computer screen.

Question 8

Nursing assistive personnel (NAP) finds a patient on the floor 30 minutes after the patient
ambulated with physical therapy. What information should be charted by the NAP on the
incident report?
a. “Patient fell out of bed and landed on the floor.”
b. “Patient found on floor. Upper side rails up. Bed in low position.”
c. “Patient got dizzy and fell although ambulated with physical therapy earlier.”
d. “Patient unfortunately slipped and fell.”

Answer 8

b. “Patient found on floor. Upper side rails up. Bed in low position.”

Question 9

An incident report is completed as a result of the pharmacy sending the wrong medication to
the unit, even though the medication wasn’t administered. A student asks the nurse why this
was needed. What response by the nurse is best?
a. To make sure that the pharmacy was blamed for the error and not the nurse
b. To help the pharmacy identify risks and prevent this situation from occurring again
c. To prevent the hospital from a medical malpractice suit
d. To get the health care provider’s attention about ordering medications

Answer 9

b. To help the pharmacy identify risks and prevent this situation from occurring again

Question 10

The nursing staff have been using the SBAR format to structure communication for the past
few months. Successful implementation of this system would be present if the nurse manager
made which statement?
a. “There are fewer omissions in patient care than before implementing this system.”
b. “Fewer nurses are coming in late when they are scheduled to work.”
c. “The medications are given on time now.”
d. “The patient length of stay has decreased since last year.”

Answer 10

a. “There are fewer omissions in patient care than before implementing this system.”

Question 11

The nursing staff are assisting nursing students in learning military time for documenting.
Instruction by the nurses has been effective if the students identify that which entry reflects 40 minutes after midnight?
a. 0040
b. 1240
c. 0004
d. 0400

Answer 11

a. 0040

Question 12

The following is an example of what part of the SBAR communication mnemonic?
“Her blood pressure has decreased from 140/90 to 100/50 and she vomited 400 mL of bright
red blood.”
a. S
b. A
c. R
d. B

Answer 12

a. S

Question 13

Electronic health records (EHRs) can improve patient care. The following is an example of an
alert in an EHR. (Select all that apply.)
a. Notification of medication being overdue
b. Change in patient’s blood pressure that exceeds parameters
c. Order entered for a medication the patient is allergic to
d. Routine lab orders
e. Critical lab value

Answer 13

a. Notification of medication being overdue
b. Change in patient’s blood pressure that exceeds parameters
c. Order entered for a medication the patient is allergic to
e. Critical lab value

Question 14

The Joint Commission standards require all patients admitted to a health care agency to have
the following documented. (Select all that apply.)
a. Self-care assessment
b. Discharge planning needs
c. Environment assessment
d. Physical assessment
e. Religious practices

Answer 14

a. Self-care assessment
b. Discharge planning needs
c. Environment assessment
d. Physical assessment

Question 15

The following is an excerpt of a discharge planning note. What elements of discharge
planning are present in this example? (Select all that apply.)
“Discussed learning about insulin injection technique. Patient will administer his own
injection next time.”

a. Measurable patient goal
b. Progress toward goal
c. Need for referral
d. Discharge date

Answer 15

a. Measurable patient goal

b. Progress toward goal

Question 16

In a POMR charting method of documentation, which of the following items are used? (Select
all that apply.)
a. Progress notes
b. Database
c. Medical diagnosis
d. Problem list
e. Care plan

Answer 16

a. Progress notes
b. Database
d. Problem list
e. Care plan