ATI COMPREHENSIVE EXIT EXAM

ATI COMPREHENSIVE EXIT EXAM 1. A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document? 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional a. pain. VO Dr. Day/J. Winds, RN, read back. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional b. pain. TO J. Winds, RN, read back. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional c. pain. TO Dr. Day/J. Winds, RN, read back. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional d. pain. TO J. Winds, RN. ANS: C The nurse receiving a TO or VO enters the complete order into the computer using the computerized provider order entry (CPOE) software or writes it out on a physician’s order sheet for entry in the computer as soon as possible. After you have taken the order, read the order back, using the “read back” process, and document that you did this to provide evidence that the information received (such as call back instructions and/or therapeutic orders) was verified with the provider. An example follows: “10/16/2015 (08:15), Change IV fluid to Lactated Ringers with Potassium 20 mEq/L to run at 125 mL/hr. TO: Dr. Knight/J. Woods, RN, read back.” VO stands for verbal order, not telephone order. The health care provider’s name and read back must be included in the chart entry. 2. A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up? To be proficient in informatics, a nurse should be able to discover, a. retrieve, and use information in practice. A nurse needs to know how to find, evaluate, and use information b. effectively. If a nurse has computer competency, the nurse is competent in c. informatics. d. Nursing informatics is a recognized specialty area of nursing practice. ANS: C When the staff make an incorrect statement, then the nurse needs to follow up. Competence in informatics is not the same as computer competency. All the rest are correct information so the nurse does not need to follow up. To become competent in informatics, you need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. Nursing informatics is a specialty that integrates the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research. 3. 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? a. Clinical decision support system b. Nursing process design c. Critical pathway design d. Computerized provider order entry system ANS: C One design model for Nursing Clinical Information Systems (NCIS) is the protocol or critical pathway design. This design facilitates interdisciplinary management of information because all health care providers use evidence-based protocols or critical pathways to document the care they provide. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions in order to generate tailored recommendations for individual patients, which are presented to nurses as alerts, warnings, or other information for consideration. The nursing process design is the most traditional design for an NCIS. This design organizes documentation within well-established formats such as admission and postoperative assessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) systems allow health care providers to directly enter orders for patient care into the hospital’s information system. 4. A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? a. Use the same password all the time. b. Share password with only one other staff member. c. Print out and review computer nursing notes at home. d. Chart on the computer immediately after care is provided. ANS: D To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient’s bedside to facilitate immediate documentation of information as it is collected. A good system requires frequent, random changes in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy all papers containing personal information immediately after you use them. Taking nursing notes home is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality. 5. Which entry will require follow-up by the nurse manager? 0800 Patient states, “Fell out of bed.” Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, “Did not pass out.” Assisted back to bed. Call bell within reach. Bed monitor on. ——————-Jane More, RN 0810 Notified primary care provider of patient’s status. New orders received. ——————-Jane More, RN 0815 Portable x-ray of L hip taken in room. States, “I feel fine.” ——————-Jane More, RN 0830 Incident report completed and placed on chart. ——————-Jane More, RN a. 0800 b. 0810 c. 0815 d. 0830 ANS: D Do not include any reference to an incident in the medical record; therefore, the nurse manager must follow up. A notation about an incident report in a patient’s medical record makes it easier for a lawyer to argue that the reference makes the incident report part of the medical record and therefore subject to attorney review. When an incident occurs, document an objective description of what happened, what you observed, and the follow-up actions taken, including notification of the patient’s health care provider in the patient’s medical record. Remember to evaluate and document the patient’s response to the incident.