OA 220 Flashcards

1
Q

A doctor receives an urgent phone call from a nurse caring for a patient while the doctor is at a coffee shop ordering breakfast. How should the doctor proceed to prevent a possible violation of HIPAA?

A

The doctor should ask the nurse to text him rather than calling as the doctor is in a public location and unable to speak with the nurse on the phone at this time.

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2
Q

During a recent review for a clinical documentation improvement for an ambulatory surgery center a nurse observed that the incorrect current procedural terminology (CPT) codes have been entered for over 100 outpatient procedures. Which set of standards for
professional behaviors is the nurse demonstrating when reporting an occurrence to the supervisor?

A

American Health Information Management Association (AHIMA) Code of Ethics.

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3
Q

A nurse has been asked to set up a secure data capture and collection process for the
evaluation of a practice process improvement project. Which approach should the nurse use to help ensure data security?

A

Collect data on secure access servers.

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4
Q

Information that can be used to identify an individual is known as PHI. This information
includes addresses, medical record numbers, demographic information, and other elements that could potentially lead to the identity of the individual. Which term is used to reference this information?

A

Individually identifiable health information.

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5
Q

Which information technology best practice helps prevent HIPAA violations as an organization?

A

Requiring devices to be password protected.

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6
Q

In which area of informatics nursing should promote the adoption of and implantation of telehealth programs to increase access to health services belong?

A

Advocacy.

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7
Q

What is one role a nurse can have in the formulation of health policy?

A

Representing nurses on a national task force.

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8
Q

A provider asks a nurse caring for a patient to send an update on the patient’s condition in two hours. Which method is appropriate for the nurse to communicate this information to the provider given the laws that protect personal health care information?

A

Secure chat.

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9
Q

In 1996, the United States passed HIPPA to modernize the flow of healthcare information and provide stipulators to protect this information and provide stipulations to protect this information from fraud and theft. Which information is specifically protected under this act?

A

A patient’s test results.

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10
Q

Which federal government entity supports the adoption of health information technology and promotes a nationwide exchange of HIPPA?

A

Office of National Coordinator.

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11
Q

A worker compensation insurance company calls a clinic to verify charges for a patient. A billing clerk verifies the patient’s charges over the phone. Which allows the clerk to provide the patient’s information to the insurance company?

A

HIPAA Privacy Rule.

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12
Q

Clinical users often request new technology applications or software features to reduce
inefficiencies. An informatics nurse specialist may receive many requests that not all can or should be implemented. Which information should an informatics nurse specialist use to build the business case for the technology review committee to determine which requests should be approved?

A

The cost of implementations, the cost of maintenance, and the return on investment.

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13
Q

What is the benefit of moving information in patient records previously stored in notes into a form or check box?

A

Forms and checkboxes improve the reliability of data.

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14
Q

Healthcare organizations are encouraged to use standard language in the data they collect. This allows an organization to recommend improvements based on health information technology. What is the benefit of standardizing the data each organization must collect answers?

A

Information can be combined from multiple organizations to research.

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15
Q

After a medication error, a workgroup is brought together to review a patient’s health record and determine how the error reached the patient. Which type of root cause analysis should be used in the scenario to map out the various causes that affected the sentient even?

A

Fishbone diagram.

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16
Q

A clinical transformation group at a healthcare facility uses a flowchart to map the process of admitting a patient from the emergency department to an inpatient.

A

Using a flowchart, the group can identify unnecessary steps in the admission process.

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17
Q

When benchmarking is an appropriate evaluation method for comparing data before and after adopting new guidelines?

A

When determining improvement in patient outcomes after a change in process.

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18
Q

The HIPPA requires reporting standards to be followed if more than 500 incidents of unsecured PHI were released or authorized access took place. These reporting standards require notification to both the regulatory agency as well as individuals within the specific period. What is considered a reasonable period to file a violation report?

A

60 days.

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19
Q

In which scenario does a nurse exemplify effective documentation?

A

A nurse records medication and the patient’s response directly into a computer workstation.

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20
Q

How does the CPOE support quality patient care?

A

By checking for drug-to-drug interactions.

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21
Q

A nurse working at a community clinic has access to an EHR. A patient recently received care at the clinic. The patient’s mother is calling to access the patient’s medical records. How should the nurse respond to the matter?

A

Tell her that the clinic is unable to provide her daughter’s medical records.

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22
Q

Which scenario demonstrates a CDSS best practice alert?

A

An alert is triggered before completing an electronic prescription of sildenafil citrate for a patient who is taking isosorbide mononitrate.

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23
Q

An informatics nurse is facilitating a discussion on the differences between intranet and extranet software with nurse managers. The nurse provides an example of organizational formulary access (via the intranet) versus access to a drug informational portal (via the extranet) What is the benefit of having both intranet and extranet access in the healthcare organization?

A

It facilitates EBP.

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24
Q

Which data analytics is beneficial in addressing the hospital staffing needs of a large medical center during holidays and weekends?

A

Predictive analytics.

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25
Q

After reviewing documentation from the HER and interviewing multiple staff involved in the process, nursing leadership has decided to make changes to the process of admitting a patient from the ER to a medical unit. Which evaluation tool did the nurse leadership use in this analysis?

A

Workflow chart.

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26
Q

What characteristic of patient management software should the informatics nurse validate as fundamental?

A

Adhering to legislation for policies and procedures about data privacy and security provisions for medical information.

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27
Q

Which expectations does the HIPAA provide to protect the PHI of patients?

A

It stipulates how personally identifiable information is protected from fraud and theft.

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28
Q

A recent report showed a sudden increase in nurses overriding medications when using a medical dispensing machine. A nurse educator is asked to create an education plan to address this increase. What should the nurse educator do first to assess the cause of this sudden increase?

A

Determine the reason for overriding and validate the reasons with the nurses.

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29
Q

A nurse educator is asked to work with the nurses in the command center of a tele-ICU to address their hesitancy in using new technology. Which benefit of tele-ICU monitoring should be emphasized to address this hesitancy?

A

It provides consistent support and expertise.

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30
Q

A rural hospital is planning to implement teleradiology in its busy ER. What is a security consideration in teleradiology implementation?

A

Access to patients’ images.

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31
Q

An ambulatory office uses telehealth to monitor patients with chronic illness by using in- home technology to transmit patient data to the office. Which type of telehealth is being used in this situation?

A

Remote patient monitoring.

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32
Q

A facility has recently implemented dictation at the point of care and clinicians have voiced satisfaction with new technology. What is the expected evaluation outcome of implementing this feature?

A

Clinicians can immediately edit and save documents.

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33
Q

A nurse manager reviews an incident report for a medication error. The physician admits to ignoring the EHR messages and ordering a medication the patient is allergic to. The physician describes being desensitized to the multiple alerts received throughout the shift. The nurse manager initiates a process improvement project aimed at preventing alert fatigue. What is an appropriate first action for the nurse manager?

A

Organize a multidisciplinary alert management team.

34
Q

An ICU nurse electronically captures patients’ vital signs into the EHR. What is the benefit of the electronic capture of patient data?

A

Improving the accuracy of vital sign documentation.

35
Q

A nurse receives a warning message when ordering blood products for a patient with religious conflicts with blood transfusions. Which health information technology assisted the nurse?

A

Clinical decision support (CDS).

36
Q

Hospital staff are struggling to meet compliance with vaccine screening requirements due to a lack of training methods such as classes, flyers, and storyboards, and nurses are concerned about the time it will take them to review lengthy training documents. An electronic approach to education and streamlining this process is suggested. Which resolution is appropriate in this scenario?

A

Develop computer based training.

37
Q

What is an example of data mining to improve patient outcomes?

A

Generating the percentage of patients with therapeutic Hb1c.

38
Q

Perioperative staff at a hospital use a whiteboard to manually track patients. Recently, surgeons have complained that the turnaround time between surgical cases has increased and blame the manual tracking system. An informatics nurse recommends expanding the use of an existing surgical information system (SIS). What would improve this workflow?

A

Switching to electronic boards for operating rooms.

39
Q

A patient experiences a medical emergency while traveling. Hospital clinicians need rapid access to the patient’s previous medical history from the out-of-state primary care provider. Which health information technology should hospital clinicians use?

A

Transmitting data using health information exchange.

40
Q

Hospital clinicians have voiced dissatisfaction with the multiple steps and passwords required to access the EHRs. The informatics nurse researches the use of biometric technology as a solution and plans to propose this technology for approval. What is a hurdle in implementing biometric technology?

A

Implementation cost.

41
Q

Which health information system is used by imaging departments and includes scheduling appointments, storing patients’ results, generating reports, and billing for imaging services.

A

Radiology information system (RIS)

42
Q

What does the acronym HIPPA stand for?

A

Health Information Portability and Accountability Act.

43
Q

A discharge nurse recognizes patients are often disengaged in discharge education because they are distracted and impatiently waiting to return home. Which strategy should the nurse recommend to increase patient engagement toward discharge education?

A

Implement a discharge readiness checklist to review throughout the hospital stay.

44
Q

Which expectation does the HIPPA provide to protect the health information of patients?

A

It stipulates how personally identifiable information is protected from fraud and theft.

45
Q

What should a nurse assess before teaching patients information about how to care for their health to enhance compliance and improve health outcomes?

A

Level of health literacy.

46
Q

Which health literacy guidelines are associated with increased compliance for most patients and require careful nursing consideration to prepare patient education?

A

A fifth-grade reading level is best for comprehension.

47
Q

A patient tells a clinician they would like to have their family participate in patient training and education what should the clinician do to leverage patient-centered care to engage this patient’s family in patient care?

A

Ask the patient how the family should be included in the patient’s care needs.

48
Q

A nurse is preparing to teach a patient with diabetes how to best monitor blood sugar levels. Which factor would most likely affect this patient’s ability to understand the educational information in the patient portal once the patient has returned home?

A

Learning preferences.

49
Q

Which process analyzes the same data using multiple approaches to confirm data accuracy?

A

Triangulationon method.

50
Q

Clinical decision support tools help clinicians provide better care to their patients by providing alerts for potential drug interactions, allergies missed documentation, and other clinical warnings.

A

The alert should be derived from evidence-based practice.

51
Q

Which clinical note type is exempt from being shared with patients according to the US core Data for Interoperability (USCDI) standards?

A

Psychotherapy notes.

52
Q

A high number of data entry fields in EHRs can be overwhelming for staff and can make it difficult to find where information should be documented. Which informatics solution would solve this problem?

A

Documentation using drop-down menu.

53
Q

What is the danger of using unvalidated device data in a patient’s EHRs to make clinical decisions for patients?

A

Data may be inaccurate.

54
Q

Which information in the patient’s EHRs, in addition to the nursing flowsheets, and providers orders would help a nurse plan and manage fluctuations in the patient’s blood glucose levels?

A

Intake and output records.

55
Q

A nurse is planning the care for patients admitted to the hospital with Covid-19. Which information in the EHRs would help the nurse plan the care for these patients?

A

The patient’s laboratory results over the last 72 hours.

56
Q

Which information in the patient’s EHRs would help a nurse plan and manage the patient’s post-op care after open heart surgery?

A

Providers order.

57
Q

Which information in a patient EHR in addition to the nursing flowsheet would help a nurse plan and manage fluctuations in the patient’s blood sugar?

A

MAR.

58
Q

Which information in patients’ electronic health records would help a nurse plan and manage the patient’s post-op care after an appendectomy?

A

Physicians order.

59
Q

How can informatics be used to assess a person’s health literacy?

A

By evaluating a patient’s current state and determining the resources needed to identify the level of understanding.

60
Q

A nurse is receiving the report of a patient who will be transferred to the patient care unit from the emergency department. The patient is experiencing SOB, severe muscle pain, and a fever. Additional data in this patient’s electronic health record would inform the decision to implement airborne isolation precautions on admission.

A

A nasal swab culture results indicate a pending result for COVID-19.

61
Q

During the oncoming shift rounds, a nurse receives a report that a patient with multiple episodes of loose stool has a new lab result for a stool specimen and may need to be placed in contact precautions. Which data in the patient’s EHR would support the nurse’s action to place the patient on contact precautions?

A

I/O flowsheet and a positive lab result for c-diff.

62
Q

Which information in an electronic health record would help a nurse plan the care for a patient with COPD?

A

Complete health history.

63
Q

Which data in the patient’s EHR would support a decision to implement airborne precautions?

A

The radiology report impression and the history and physical order the last 24 hours.

64
Q

Which data in a patient electronic health record would inform the decision would inform the decision to implement contact precautions?

A

The laboratory report indicates methicillin-resistant staphylococcus aureus.

65
Q

A patient is admitted to a hospital. The patient is reporting chills, fever, and loss of appetite over the last seven days. Which data in this patient’s EHR would inform the decision to implement infection control precautions?

A

Laboratory results.

66
Q

After an extensive review of patient records from the ICU, it is determined that a combination of nursing interventions performed together can drastically decrease patient falls, When reviewing another ICU with similarly low rates of falls, this same conclusion could not be reached. What is the likely explanation for this?

A

Different reviews can draw different conclusions.

67
Q

A high number of data entry fields in EHRs can be overwhelming for staff and can make a difficult to find where information should be documented. Which informatics solution would solve the problem?

A

Documentation using drop-down menus.

68
Q

Which view in an electronic health record should be reviewed to determine if a patient’s blood glucose level is stabilizing?

A

Graphical trending over time.

69
Q

What are the benefits of patients engaging with the patient health portal?

A

Lower readmission rates and increased patient empowerment.

70
Q

A patient who does not have housing is admitted to a hospital with complaints of stomach pains, nausea, and fatigue. The patient’s history and physical IV drug user. Which data in this patient’s electronic health record would support the implementation of an infection control policy?

A

A blood serum sample indicating the presence of Hep A- Specific IgM antibodies.

71
Q

A nurse understands that health literacy is an important factor in improving patient outcomes. How can informatics be used to improve health literacy?

A

By offering options for multilanguage learners and different reading levels.

72
Q

A stroke program coordinator wants to know which stroke metrics were met each month over the past year.

A

Bar graph.

73
Q

Which scenario describes using a focus group for the evaluation of technology with the intent to develop successful human-computer interactions?

A

Gathering users to discuss the technology.

74
Q

An informatics nurse discovers that the hospital’s health information technology has problems related to possible capacity explosion and processing needs from patient care data. Which solution should the nurse initiate?

A

Review existing management systems and identify possible vendors that will provide a safe and effective solution to the problem.

75
Q

The hospital administrator appoints an informatics nurse to lead a team, of healthcare and IT professionals in the selection of EHR software. Which first should the informatics nurse initiate?

A

Gather the requirements.

76
Q

A clinical informatics nurse specialist wants to optimize the EHR software to decrease documentation time. Which method of data collection should this clinical informatics nurse specialist use to prioritize the areas of improvement?

A

Interviews with affected users.

77
Q

Which data visualization should be used to display the length of stay for an oncology patient during one year at one hospital?

A

Histogram chart.

78
Q

Which set of data should be displayed with bar graphs?

A

Blood transfusions were not charged or compared to the total number of transfusions given in a department.

79
Q

Under which condition can PHI be released without patient consent?

A

When information requested is required for payment of treatment provided.

80
Q

The nursing director of a hospital is preparing an in-house presentation about the nursing minimum data set (NMDS). Which information represents the service elements of NMDS?

A

Nursing, diagnosis, intervention, outcome.