Question 1

Identify the purposes of a health care record.

Accepted Answer

A)  Communication 
B)  Legal documentation 
C)  Reimbursement 
D)  Education 
E)  Research
F) Nursing process 
A)  Communication 
B)  Legal documentation 
C)  Reimbursement 
D)  Education 
E)  Research
F) Nursing process A,B,C,D,E

Question 2

A home health nurse is preparing for an initial home visit.Which information should be included in the patient's home care medical record?

Accepted Answer

A)  Nursing process form 
B)  Step-by-step skills manual 
C)  A list of possible procedures 
D)  Reports to third party payers 
A)  Nursing process form 
B)  Step-by-step skills manual 
C)  A list of possible procedures 
D)  Reports to third party payers D

Question 3

A nurse is using the source record and wants to find the daily weights.Where should the nurse look?

Accepted Answer

A)  Database 
B)  Medical history and examination 
C)  Progress notes 
D)  Graphic sheet and flow sheet 
A)  Database 
B)  Medical history and examination 
C)  Progress notes 
D)  Graphic sheet and flow sheet D

Question 4

A patient has a diagnosis of pneumonia.Which entry should the nurse chart to help with financial reimbursement?

Accepted Answer

A)  Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. 
B)  Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. 
C)  Breathing without difficulty. Sitting up in bed watching TV. Had a good day. 
D)  Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours. 
A)  Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. 
B)  Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. 
C)  Breathing without difficulty. Sitting up in bed watching TV. Had a good day. 
D)  Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

Question 5

A nurse preceptor is working with a student nurse.Which behavior by the student nurse will require the nurse preceptor to intervene?

Accepted Answer

A)  The student nurse reviews the patient's medical record. 
B)  The student nurse reads the patient's plan of care. 
C)  The student nurse shares patient information with a friend. 
D)  The student nurse documents medication administered to the patient. 
A)  The student nurse reviews the patient's medical record. 
B)  The student nurse reads the patient's plan of care. 
C)  The student nurse shares patient information with a friend. 
D)  The student nurse documents medication administered to the patient.

Question 6

Which situation will require the nurse to obtain a telephone order?

Accepted Answer

A)  As the nurse and primary care provider leave a patient's room, the primary care provider gives the nurse an order. 
B)  At 0100, a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood. 
C)  At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order. 
D)  A nurse reads an order correctly as written by the primary care provider in the patient's medical record. 
A)  As the nurse and primary care provider leave a patient's room, the primary care provider gives the nurse an order. 
B)  At 0100, a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood. 
C)  At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order. 
D)  A nurse reads an order correctly as written by the primary care provider in the patient's medical record.

Question 7

A nurse is creating a plan to reduce data entry errors and maintain confidentiality.Which guidelines should the nurse include?

Accepted Answer

A)  Create a password with just letters. 
B)  Bypass the firewall. 
C)  Use a programmed speed-dial key when faxing. 
D)  Implement an automatic sign-off. 
E)  Impose disciplinary actions for inappropriate access.
F) Shred papers containing personal health information (PHI). 
A)  Create a password with just letters. 
B)  Bypass the firewall. 
C)  Use a programmed speed-dial key when faxing. 
D)  Implement an automatic sign-off. 
E)  Impose disciplinary actions for inappropriate access.
F) Shred papers containing personal health information (PHI).

Question 8

A nurse is preparing a change-of-shift report for a patient who had chest pain.Which information is critical for the nurse to include?

Accepted Answer

A)  Pupils equal and reactive to light 
B)  The family is a "pain" 
C)  Had poor results from the pain medication 
D)  Sharp pain of 8 on a scale of 1 to 10 
A)  Pupils equal and reactive to light 
B)  The family is a "pain" 
C)  Had poor results from the pain medication 
D)  Sharp pain of 8 on a scale of 1 to 10

Question 9

A nurse is giving a hand-off report to the oncoming nurse.Which information is critical for the nurse to report?

Accepted Answer

A)  The patient had a good day with no complaints. 
B)  The family is demanding and argumentative. 
C)  The patient has a new pain medication, Lortab. 
D)  The family is poor and had to go on welfare. 
A)  The patient had a good day with no complaints. 
B)  The family is demanding and argumentative. 
C)  The patient has a new pain medication, Lortab. 
D)  The family is poor and had to go on welfare.

Question 10

After providing care,a nurse charts in the patient's record.Which entry should the nurse document?

Accepted Answer

A)  Appears restless when sitting in the chair 
B)  Drank adequate amounts of water 
C)  Apparently is asleep with eyes closed 
D)  Skin pale and cool 
A)  Appears restless when sitting in the chair 
B)  Drank adequate amounts of water 
C)  Apparently is asleep with eyes closed 
D)  Skin pale and cool

Question 11

A nurse developed the following discharge summary sheet.Which critical information should be added?

Accepted Answer

A)  Kardex form 
B)  Admission nursing history 
C)  Mode of transportation 
D)  SOAP notes 
A)  Kardex form 
B)  Admission nursing history 
C)  Mode of transportation 
D)  SOAP notes

Question 12

A nurse wants to integrate all pertinent patient information into one record,regardless of the number of times a patient enters the health care system.Which term should the nurse use to describe this system?

Accepted Answer

A)  Electronic medical record 
B)  Electronic health record 
C)  Electronic charting record 
D)  Electronic problem record 
A)  Electronic medical record 
B)  Electronic health record 
C)  Electronic charting record 
D)  Electronic problem record

Question 13

A nurse has taught the patient how to use crutches.The patient went up and down the stairs using crutches with no difficulties.Which information will the nurse use for the "I" in PIE charting?

Accepted Answer

A)  Patient went up and down stairs 
B)  Deficient knowledge regarding crutches 
C)  Demonstrated use of crutches 
D)  Used crutches with no difficulties 
A)  Patient went up and down stairs 
B)  Deficient knowledge regarding crutches 
C)  Demonstrated use of crutches 
D)  Used crutches with no difficulties

Question 14

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide.Which type of system/design will the nurse be using?

Accepted Answer

A)  Clinical decision support system 
B)  Nursing process design 
C)  Critical pathway design 
D)  Computerized provider order entry system 
A)  Clinical decision support system 
B)  Nursing process design 
C)  Critical pathway design 
D)  Computerized provider order entry system

Question 15

Which behaviors indicate that the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)?

Accepted Answer

A)  Writes the patient's room number and date of birth on a paper for school 
B)  Prints/copies material from the patient's health record for a graded care plan 
C)  Reviews assigned patient's record and another unassigned patient's record 
D)  Reads the progress notes of assigned patient's record 
E)  Gives a change-of-shift report to the oncoming nurse about the patient
F) Discusses patient care with the hospital volunteer 
A)  Writes the patient's room number and date of birth on a paper for school 
B)  Prints/copies material from the patient's health record for a graded care plan 
C)  Reviews assigned patient's record and another unassigned patient's record 
D)  Reads the progress notes of assigned patient's record 
E)  Gives a change-of-shift report to the oncoming nurse about the patient
F) Discusses patient care with the hospital volunteer

Question 16

A nurse is a member of an interdisciplinary team that uses critical pathways.According to the critical pathway,on day 2 of the hospital stay,the patient should be sitting in the chair.It is day 3,and the patient cannot sit in the chair.What should the nurse do?

Accepted Answer

A)  Focus charting using the DAR format. 
B)  Add this data to the problem list. 
C)  Document the variance in the patient's record. 
D)  Report a positive variance in the next interdisciplinary team meeting. 
A)  Focus charting using the DAR format. 
B)  Add this data to the problem list. 
C)  Document the variance in the patient's record. 
D)  Report a positive variance in the next interdisciplinary team meeting.

Question 17

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records?

Accepted Answer

A)  The nurse determines the degree to which standards of care are met by reviewing patients' health records. 
B)  The nurse realizes that care not documented in patients' health records still qualifies as care provided. 
C)  The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. 
D)  The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment. 
A)  The nurse determines the degree to which standards of care are met by reviewing patients' health records. 
B)  The nurse realizes that care not documented in patients' health records still qualifies as care provided. 
C)  The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. 
D)  The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment.

Question 18

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart.What is the preceptor's best response?

Accepted Answer

A)  "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care." 
B)  "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs." 
C)  "A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities." 
D)  "A change-of-shift report provides important information to caregivers and develops relationships within the health care team." 
A)  "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care." 
B)  "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs." 
C)  "A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities." 
D)  "A change-of-shift report provides important information to caregivers and develops relationships within the health care team."

Question 19

A nurse obtained a telephone order from a primary care provider for a patient in pain.Which chart entry should the nurse document?

Accepted Answer

A)  12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. 
B)  12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back. 
C)  12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. 
D)  12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN. 
A)  12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. 
B)  12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back. 
C)  12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. 
D)  12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.

Question 20

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough.When is the best time the nurse should start discharge planning for this patient?

Accepted Answer

A)  Upon admission 
B)  Right before discharge 
C)  After the congestion is treated 
D)  When the primary care provider writes the order 
A)  Upon admission 
B)  Right before discharge 
C)  After the congestion is treated 
D)  When the primary care provider writes the order

Exam 74: Documentation and Informatics

Identify the purposes of a health care record.

A home health nurse is preparing for an initial home visit.Which information should be included in the patient's home care medical record?

A nurse is using the source record and wants to find the daily weights.Where should the nurse look?

A patient has a diagnosis of pneumonia.Which entry should the nurse chart to help with financial reimbursement?

A nurse preceptor is working with a student nurse.Which behavior by the student nurse will require the nurse preceptor to intervene?

Which situation will require the nurse to obtain a telephone order?

A nurse is creating a plan to reduce data entry errors and maintain confidentiality.Which guidelines should the nurse include?

A nurse is preparing a change-of-shift report for a patient who had chest pain.Which information is critical for the nurse to include?

A nurse is giving a hand-off report to the oncoming nurse.Which information is critical for the nurse to report?

After providing care,a nurse charts in the patient's record.Which entry should the nurse document?

A nurse developed the following discharge summary sheet.Which critical information should be added?

A nurse wants to integrate all pertinent patient information into one record,regardless of the number of times a patient enters the health care system.Which term should the nurse use to describe this system?

A nurse has taught the patient how to use crutches.The patient went up and down the stairs using crutches with no difficulties.Which information will the nurse use for the "I" in PIE charting?

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide.Which type of system/design will the nurse be using?

Which behaviors indicate that the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)?

A nurse is a member of an interdisciplinary team that uses critical pathways.According to the critical pathway,on day 2 of the hospital stay,the patient should be sitting in the chair.It is day 3,and the patient cannot sit in the chair.What should the nurse do?

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records?

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart.What is the preceptor's best response?

A nurse obtained a telephone order from a primary care provider for a patient in pain.Which chart entry should the nurse document?

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough.When is the best time the nurse should start discharge planning for this patient?

Health and Wellness

The Canadian Health Care Delivery System

The Development of Nursing in Canada

Community Health Nursing Practice

Theoretical Foundations of Nursing Practice

Research As a Basis for Practice

Nursing Values and Ethics

Legal Implications in Nursing Practice

Global Health, culture, and Diversity

Nursing Leadership, management, and Collaborative Practice

Critical Thinking in Nursing Practice

Nursing Assessment and Diagnosis

Planning and Implementing Nursing Care

Evaluation of Nursing Care

Documenting and Reporting

Nursing Informatics and Canadian Nursing Practice

Communication

Caring in Nursing Practice

Family Nursing

Patient Education

Developmental Theories

Conception Through Adolescence

Young to Middle Adulthood

Older Adulthood

Self-Concept

Sexuality

Spiritual Health

The Experience of Loss, death, and Grief

Stress and Adaptation

Vital Signs

Health Assessment and Physical Examination

Infection Control

Medication Administration

Complementary and Alternative Therapies

Activity and Exercise

Safety

Hygiene

Cardiopulmonary Functioning and Oxygenation

Fluid, electrolyte, and Acid-base Balances

Sleep

Pain Assessment and Management

Nutrition

Urinary Elimination

Bowel Elimination

Mobility and Immobility

Skin Integrity and Wound Care

Sensory Alterations

Care of Surgical Patients

the Health Care Delivery System

Community-Based Nursing Practice

Theoretical Foundations of Nursing Practice

Evidence-Based Practice

Health and Wellness

Caring in Nursing Practice

Caring for the Cancer Survivor

Culture and Ethnicity

Caring for Families

Developmental Theories

Conception Through Adolescence