TEST 2 - UNIT C - CH 5 - INFORMATICS

Question 1

 List three common methods of problem‑oriented charting with definitions of their acronyms.

Answer 1

● SOAP

● PIE

● DAR (focus charting)

Question 2

SOAP ◯ S

Answer 2

Subjective data

Question 3

SOAP ◯ O

Answer 3

Objective data

Question 4

SOAP ◯ A

Answer 4

Assessment (includes a nursing diagnosis based on the assessment)

Question 5

SOAP ◯ P

Answer 5

Plan

Question 6

PIE ◯ P

Answer 6

Problem

Question 7

PIE ◯ I

Answer 7

Intervention

Question 8

PIE ◯ E

Answer 8

Evaluation

Question 9

DAR ◯ D

Answer 9

Data

Question 10

DAR ◯ A

Answer 10

Action

Question 11

DAR ◯ R

Answer 11

Response

Question 12

1. A nurse is preparing information for a change‑of‑shift report. Which of the following information should the nurse include in the report?
   A. Input and output for the shift
   B. Blood pressure from the previous day
   C. Bone scan scheduled for today
   D. Medication routine from the medication administration record

Answer 12

A. Unless there is a significant change in intake and output, the oncoming nurse can read that information in the chart.
B. Unless there is a significant change in blood pressure measurements since the previous day, the oncoming nurse can read that information in the chart.
C. CORRECT: The bone scan is important because the nurse might have to modify the client’s care to accommodate leaving the unit.
D. Unless th

Question 13

2. A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.)
   A. A single electronic records password is provided for nurses on the same unit.
   B. Family members should provide a code prior to receiving client health information.
   C. Communication of client information can occur at the nurses’ station.
   D. A client can request a copy of their medical record.
   E. A nurse can photocopy a client’s medical record for transfer to another facility.

Answer 13

2. A. The HIPAA Privacy Rule requires the protection of clients’ electronic records. The rule states that electronic records must be password-protected and each staff person should use an individual password to access information.
   B. CORRECT: The HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. Many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code.
   C. CORRECT: The HIPAA Privacy Rule states that communication about a client should only take place in a private setting where unauthorized individuals cannot overhear it. A unit nurses’ station is considered a private and secure location.
   D. CORRECT: The HIPAA Privacy Rule states that clients have a right to read and obtain a copy of their medical record.
   E. CORRECT: The HIPAA Privacy Rule states that nurses can only photocopy a client’s medical record if it is to be used for transfer to another facility or provider.

Question 14

3. A charge nurse is reviewing documentation w/ a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client’s record? (Select all that apply.)
   A. Cover errors with correction fluid, and write in the correct information.
   B. Put the date and time on all entries.
   C. Document objective data, leaving out opinions.
   D. Use as many abbreviations as possible.
   E. Wait until the end of the shift to document.

Answer 14

3. A. Correction fluid implies that the nurse might have tried to hide the previous documentation or deface the medical record.
   B. CORRECT: The day and time confirm the recording of the correct sequence of events.
   C. CORRECT: Documentation must be factual, descriptive, and objective, without opinions or criticism.
   D. Too many abbreviations can make the entry difficult to understand. Nurses should minimize use of abbreviations, and use only those the facility approves.
   E. Documentation should be current. Waiting until the end of the shift can result in data omission.

Question 15

4. A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply).
   A. Medication error
   B. Needlesticks
   C. Conflict with provider and nursing staff
   D. Omission of prescription
   E. Missed specimen collection of a prescribed laboratory test

Answer 15

4. A. CORRECT: Complete an incident report regarding a medication error.
   B. CORRECT: Complete an incident report regarding a needlestick.
   C. Report a conflict with a provider and nursing staff to the charge nurse or nurse manager.
   D. CORRECT: Complete an incident report following an omission of a prescription.
   E. Report missed specimen collection of a prescribed laboratory test.

Question 16

5. A nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.)
   A. Repeat the details of the prescription back to the provider.
   B. Have another nurse listen to the telephone prescription.
   C. Obtain the provider’s signature on the prescription within 24 hr.
   D. Decline the verbal prescription because it is not an emergency situation.

Answer 16

5. A. CORRECT: The nurse should repeat the medication’s name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation.
   B. CORRECT: Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication.
   C. CORRECT: The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr).
   D. Unrelieved pain can become an emergency situation without the appropriate pain management interventions.
   E. There is no need to inform the charge nurse every time a nurse receives a medication prescription, whether by telephone, verbally, or in the medical record.