Practice Question ch 3 Flashcards
The nursing preceptor is preparing to speak with the new licensed practical/vocational nurse (LPN/LVN) regarding documentation. Which statement by the preceptor is correct?
a. “It is important to use only approved medical terms and abbreviations when documenting in the electronic health record (EHR).”
b. “Our facility discourages nurses from using complete words when documenting because it takes up too much space in the chart.”
c. “To prevent errors, our facility does not allow the use of abbreviations for documentation.”
d. “The physician uses more abbreviations when writing orders than the nurse uses when documenting.”
1
The patient asks the LPN/LVN if he can take his chart with him on discharge from the hospital. Which response by the nurse is most accurate?
a. “The chart has confidential information in it and cannot be taken out of the facility.”
b. “The chart belongs to you, so I will check to see whether this is permissible.”
c. “We need to complete the proper forms for you to take your chart with you.”
d. “The chart is the property of the hospital, but if you need copies of your records, we can arrange that for you.”
4
When reviewing information regarding the problem-oriented medical record (POMR), the LPN/LVN correctly identifies which guideline?
a. The problem list has only active and resolved problems
b. only the physician charts on the progress notes.
c.The charting format is SOAP or SOAPIER.
d. focus charting format is used with this type of record.
3
The LPN/LVN is using the SOAP method to chart. When documenting the S portion, which entry demonstrates correct documentation?
a. Patient’s vital signs are stable.
b.Patient reports left hip pain 8/10
c. Patient’s wife present during patient teaching
d. Patient ambulated 20 ft unassisted with steady gait
e.Patient reports a feeling of nausea after eating
2,5
The student nurse is correct when identifying which concept regarding documentation as being correct?
a. chart as soon and as often as necessary
. b.remember to chart only basic care information
c. leave blank lines for others if asked
d. chart facts with use of judgmental terms if needed
1
Understanding that health care personnel must respect the confidentiality of patient records, which action by the nurse is appropriate?
a. looking at a friend’s chart to see the diagnosis
b. stating that only the Patient Care Partnership advocates confidentiality
c. reading charts only for professional reason
d. sharing information from a chart to protect a friend
3
Following orientation to the facility’s computer system, which statement by the new nurse is most accurate?
a. “I can save on charting time once I am comfortable using this system.”
b. “The computer system is not that efficient.”
c. “Documentation can be done only on a shared terminal at the desk.”
d. “Most computerized systems lack security measures to protect confidentiality.”
1
The nurse demonstrates knowledge of correctly completing an incident report with which action?
a. documenting in the chart that the incident report has been filed.
b.having all parties involved sign the report
c. asking the supervising nurse to complete the incident report
d. documenting facts regarding the incident
4
Which statement is correct about formats for documentation? (Select all that apply)
a. Focus charting is a goal-oriented system.
b.clinical pathways are the most commonly used format now
c. charting by exception documents those conditions, interventions, or outcomes outside the norm.
d. standardized care plans are not cost effective.
e.EHR systems allow for patient data to be shared for collaboration of care.
c,e
Which statement is the recommended guideline for charting?
a. documentation should be lengthy and detailed
b. content that suggests a risk situation should be included.
c. one should skip lines between charting entries.
d. the patient’s name and identification number should be on all documents
4
Which statement is a safe principle of computerized charting?
a. it is acceptable to chart in advance of care being given
b. Each unit or department has its own password
c. there is no room for mistakes in computerized charting
d. do not leave patient information displayed on the monitor
4
Which accreditation agency specifies guidelines for documentation?
a. The Joint Commission (TJC)
b. American Nurses Association
c. National League of Nursing
d. American Academy of Colleges of Nursing
1
What is the primary purpose of Title II of the Health Insurance Portability and Accountability Act (HIPAA)?
a. ensure proper documentation in patient’s medical records
b. maintain privacy and confidentiality of patient’s health information
c. regulate the availability and range of group insurance plans
d. limit restrictions on insurance coverage based on preexisting conditions
2
Which statement is correct about abbreviations? (Select all that apply)
a. the nurse should be aware of any abbreviations on the “do not use” list.
b.Creating abbreviations saves time for the reader.
c.abbreviating drug names and dosages helps reduce medications errors
d. when in doubt, the nurse should use the complete word and not the abbreviation.
e.the nurse should include medical abbreviations on discharge instructions
1,4
The nurse documents in the patient record, “0830 patient appears to be in severe pain and refuses to be ambushed. Blood pressure and pulse are elevated, physician notified, and analgesic administered as ordered with adequate relief J. Doe RN.” Which statement about the documentation is most accurate?
a. The documentation is inadequate because the pain is not described on a scale of 1 to 10.
b. The documentation is good because it shows immediate responsiveness to the problem
c. the documentation is acceptable because it includes assessment, intervention, and evaluation.
d. the documentation is unacceptable because it is vague non-descriptive data without supportive data
4
