NUR 100 Exam 3 Test Banks Weeks 7, 8, & 9 Week 7 - Contemp CH 15; Fundamentals CH 26 Week 8 - Fundamentals CH 36 & 37 Week 9 - Fundamentals CH 44

NUR 100 Exam 3 Test Banks Weeks 7, 8, & 9 Week 7 - Contemp CH 15; Fundamentals CH 26 Week 8 - Fundamentals CH 36 & 37 Week 9 - Fundamentals CH 44 Contemporary - Chapter 15 1. ________ is the term used to define the capabilities and standards that an electronic health records system must be capable of utilizing in order to qualify for financial incentives provided by Medicare. ○ Meaningful use i. Meaningful use is a defined set of EHR capabilities and standards that EHR systems must meet to ensure that their full capacity is realized and for the users (hospitals and physician/provider practices) to qualify for financial incentives from Medicare. 2. Information is stored, retrieved, communicated, and managed using hardware and software that is collectively referred to as: ○ Information technology i. Information technology is the term used to identify the hardware and software that enable information to be stored, retrieved, communicated, and managed. 3. A personal decision to withhold information is considered to be associated with which patient right? ○ Privacy i. Privacy refers to the right of an individual to keep information about himself or herself from being disclosed to anyone else. Confidentiality refers to the act of limiting disclosure of private matters. Informed consent is the right to have all pertinent information before making a decision. Security refers to the means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from alteration, destruction, or loss. 4. In the clinical setting, which example of the meaningful use of electronic health records has the greatest impact on the delivery of care by the nurse? ○ Reviewing physical therapy notes before attending a patient's interprofessional care team meeting . i. Improved care coordination is one of the five priorities established as meaningful use standards. Sharing information between interprofessional healthcare team members would demonstrate that priority. The other options focus on confidentiality, which, while important, is not restricted for the clinical setting. 5. What important change have nurses implemented regarding their clinical care of patients was required by the use of point-of-care technology? ○ Becoming proficient users of the electronic tools i. Nursing today requires understanding and skill related to the variety of technological resources available to the nurse. Point-of-care technology is an essential component of nursing practice as it moves from practice that relies on memory to one that emphasizes continuous use of resources as they are needed. This means that nurses must transform from being technical experts to knowledge workers and rely on the ever-increasing and reliable computer memory versus the overburdened and fallible human memory. 6. What is the most effective way to assess the accuracy of information obtained from the Internet? ○ Research several different sources while comparing the information for similarities i. Determine whether the information is accurate by looking for documentation and referencing. Compare information on the website with information from other sources. Review links that go from the website to other Internet resources. Ensure that the links are going to high-quality resources. Currency is better ensured on websites that are frequently updated with information that is less than 5 years old. It is restrictive to rely on only a few familiar sites, especially if they are related to commercial (.com) organizations 7. How can nursing best ensure effective use of point-of-care advanced technologies in the future? ○ Potential clients must be well educated concerning the use and reliability of health care technologies i. Although some clients trust technology, others do not and may be reluctant to accept care that is driven by technology. Their fears and concerns must be addressed in order for new, more advanced technologies to be accepted and utilized to their fullest. The other options, while true, do not have as great an impact as client acceptance on the use of future technologies. 8. Potential clients must be well educated concerning theHow does computerized provider order entry (CPOE) contribute to the prevention of medical errors? (Select all that apply.) use and reliability of health care technologies ○ Providing real time checks of intervention related activities ○ Tracking of adverse patient focused events ○ Improving communication between members of the health care team ○ Providing support in the decision-making process i. CPOE functions contribute to medical error prevention through improved communication, decision support, tracking and response to adverse events, and performance checks are done in real time. The CPOE may play a role in identifying appropriate diagnostic tests and preventing duplicate or contradictory orders for tests but it does not eliminate the human role associated with the monitoring results of such testing. Fundamentals Ch. 26 1. The nurse contacts a provider about a change in a patient’s condition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the following? ○ "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record. i. Guidelines from TJC require a "read-back" on all telephone (and verbal) orders. The nurse reads a telephone order back word for word and receives confirmation that the order is correct from the health care provider who gave the order. 2. The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that apply.) ○ Using a strong password and changing your password frequently according to agency policy ○ Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed ○ Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care i. Mechanisms to protect the privacy and confidentiality of protected health information in the electronic health record include: not sharing passwords, not leaving computers with open electronic health records unattended, and preventing those not involved with a patient's care from seeing information displayed on a monitor 3. When documenting an assessment of a patient’s cardiac system in an electronic health record, the nurse uses the computer mouse to select the “WNL” statement to document the following findings: “Heart sounds S1 & S2 auscultated. Heart rate between 80–100 beats per minute, and regular. Denies chest pain.” This is an example of using which of the following documentation formats? ○ Charting-by-exception (CBE) i. Charting-by-exception (CBE) is a unique documentation format designed with the philosophy that all standards are met unless otherwise documented. Many computerized nursing documentation systems have incorporated a CBE design. Exception-based documentation systems incorporate clearly defined criteria for nursing assessment and documentation of "normal" findings. Predefined statements used to document "normal" assessment of body systems are called "within defined limits" (WDL) or "within normal limits" (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. Automated documentation within a computerized documentation system allows nurses to select a WNL (or WDL) statement or to choose other statements from a drop-down menu. 4. The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient’s electronic health record must be printed and faxed to the acute rehabilitation center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient’s information when faxing this information? (Select all that apply.) ○ Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. ○ Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. ○ After sending the fax, place the information that was printed out in a secure canister marked for shredding. i. Nurses have the legal and ethical obligation to safeguard any patient information that is printed or extracted from the electronic (or paper) health record. Best practice is to use all measures to fax information securely, and to shred any printed health record material after it has been used for the purpose intended 5. The nurse works at an agency where military time is used for documentation, and needs to document that a patient was transported to the operating room for an emergency procedure at 8 in the evening. Point to the area on the clockface below that indicates 8 in the evening in military time: ○ 6. The nurse is administering a dose of metoprolol to a patient, and is completing the steps of bar code medication administration within the EHR. As the barcode information on the medication is scanned, an alert that states “Do not administer dose if apical heart rate (HR) is <60 beats/minute or systolic blood pressure (SBP) is <90 mm Hg” appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? ○ Clinical decision support system (CDSS) i. Computer decision support systems(CDSS) are computerized programs that prompt health care providers with clinical knowledge and relevant patient information that assists with clinical decision making. A nursing CDSS uses a complex system of rules to analyze data and provide alerts to support clinical decisions made by nurses. 7. The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): ○ April 24, 2019 (0900) - Objective ○ Repositioned patient on left side. - Objective ○ Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. - Objective ○ "The pain in my incision increases every time I try to turn on my right side." - Subjective ○ S. Eastman, RN - Objective ○ Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage - Objective ○ Rates pain 7/10 at location of surgical incision. - Objective 8. The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record? ○ CPOE improves patient safety by reducing transcription errors i. Although the other answers loosely describe some positive aspects of CPOE, option 4 provides the best description of the major advantage CPOE offers—the reduction of transcription errors, which reduces medical errors and creates a safer patient care environment. 9. The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission’s “Do Not Use” list and should be clarified with the health care provider? ○ Insulin aspart 8u SQ every morning before breakfast i. In option 4, the word "unit(s)" should be written out because the letter "u" can be mistaken for "0," the number "4," or "cc." The other orders are written appropriately 10. The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon (Dr. Oakman) by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? ○ 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN i. This statement includes the date and time the health care provider was contacted, the specific name of the health care provider, descriptive details of the changes of concern noted in the patient assessment,whether any orders were received, and the name and credentials of the nurse who contacted the health care provider. 11. The nurse is preparing the information that will be provided to the staff on the next shift. Which of the following should the nurse include in the inter-shift report to nursing colleagues? ○ Instructions given to the client in a teaching plan i. A change-of-shift report should include instructions given in a teaching plan and the clients response. This should not include detailed content unless staff members ask for clarification. The nurse should relay to staff significant changes in the way therapies are given, but should not describe basic steps of a procedure. The client's diagnosis-related group is not essential background information to be shared in an inter-shift report. The nurse should not review all routine care procedures or tasks. 12. An incident report is to be completed because the client climbed over the side rails and fell to the floor. The correct reporting of an incident involves which of the following? ○ The witnessing nurse completes the report i. The nurse who witnessed the incident is the one who completes the report. Details of the incident should be objectively described. An explanation of the possible cause is not included. The sequence of events is described objectively. A notation is not included in the medical record that an incident report was written 13. Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care? ○ 0830Increased IV fluid rate to 100 mL/hr according to protocol i. Information within a recorded entry needs to be complete, containing appropriate and essential information. This notation (0830) provides the time and action taken by the nurse including the reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry (0700) does not provide the specific amount the client drank. Stating adequate is subjective, not objective. This notation (0900) does not have the client describe his or her pain or rate it according to a pain scale for comparison later. It also does not indicate whether the clients pain was in the lower left or lower right quadrant, or both. 14. The nurse makes a late entry in a clients record. Which of the following is the best example of how to document this type of situation? ○ 2:45 PMASA gr X given for temperature of 38.1 C. i. This is the best example of a late entry. The time (2:45 PM) is indicated along with the action and an objective observation. This notation (8:30 AM) is not complete. It does not indicate why the Percodan was given. What was the clients level of pain? Where was the pain located? The nurse does not need to document about herself; only the client. In this option (12:15 PM), the nurse does not indicate why the morphine was given (clients level of pain? location of pain?). This entry (8:30 PM) is not complete. It does not state the size of the wound, type of dressing used, or the clients tolerance of the procedure. 15. The following statement: Upon exertion, the client is wheezing and experiencing some dyspnea, is an example of: ○ The P of PIE i. These data are examples of the P of PIE because they describe the problem. FOCUS charting does not concentrate on only problems. It is structured according to a clients concerns. The R in DAR documentation is the response of the client. This situation describes the clients problem, not the clients response. The S in SOAP documentation represents subjective data (verbalizations of the client) 16. To locate the recording of a nurses description of the teaching provided to the client on performance of self-medication administration, one would look in a(n) ○ Discharge summary form i. A nurses description of the teaching provided to the client on performance of self-medication administration is recorded in the discharge summary form. A Kardex is a written form that contains basic client information. A Kardex contains an activity and treatment section and a nursing care plan section that organizes information for quick reference as nurses give changeof- shift report. It does not include a description of teaching that was provided to the client. An incident report is any event that is not consistent with the routine operation of a health care unit or routine care of a client (e.g., a client falls). A nursing history form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems. It provides baseline data about the client 17. The nurse has made an error and is documenting such on the clients record and notes. The action that the nurse should take is to: ○ Draw a straight line through the error and initial it. i. If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible. Also, entries should only be made in ink so they cannot be erased. Using a dark color marker to cover the error is not correct. It may appear as if the nurse was attempting to hide something or deface the record. Footnotes are not used in nursing documentation. 18. The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse: ○ Dates and signs all of the entries made in the record i. Each entry should begin with the time and end with the signature and title of the person recording the entry. All entries should be recorded legibly and in black ink because pencil can be erased. The nurse should never erase entries, never use correction fluid, or never use a pencil. The use of correction fluid could make the charting become illegible and it may appear as if the nurse were attempting to hide something or to deface the record. If the physician made an error, the nurse should not document it in the clients chart. It should be documented in an incident report. 19. What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients ○ Let me get the Registered Nurse on the phone i. A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. Saying that an order is unable to be taken and to call back in the morning is not an appropriate response and not in the clients best interest. It is best to repeat any prescribed orders back to the physician, who can then verify if it is correct or clarify the order. This is not the appropriate response. A registered nurse needs to take the verbal order, but it does not have to be the nursing supervisor. 20. The client developed a slight hematoma on his left forearm. The nurse labels the problem as an infiltrated intravenous (IV) line. The nurse elevates the forearm. The client states, My arm feels better. What is documented as the R in FOCUS charting? ○ My arm feels better i. The R in FOCUS charting is the clients response. In this case, the nurse would document, My arm feels better. Infiltrated IV line would be documented as D referring to data in FOCUS charting. Elevation of left forearm is the A in FOCUS charting. It describes the action or nursing intervention. Slight hematoma on left forearm is the D referring to data in FOCUS charting. 21. Which of the following is evaluated as a legally appropriate notation? ○ Verbalized sharp, stabbing pain along the left side of chest i. Entries should be concise, factual, and accurate. Verbalized sharp, stabbing pain along the left side of chest is an example of an objective description of a clients behavior. The nurse should not document physician made error. Instead, the nurse could chart that Dr. Green was called to clarify order for medication administration. The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry. Only objective descriptions of the clients behavior should be recorded. For example: Client states, I dont want physical therapy! I want to go home! 22. To avoid legal risks and possible lack of confidentiality associated with computerized documentation, many programs currently have ○ Periodic changes in staff passwords i. A good system of computerized documentation requires periodic changes in personal passwords to prevent unauthorized persons from tampering with records. Many programs do not have thumbprint identification restrictions. All nurses do not use the same access code. Each nurse should have his or her own password. Only centralized medical records using the client data is not a true statement. Authorized health care providers from any department can access and use the data. 23. Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy? ○ The hospital is reimbursed for the nursing care documented in the client chart i. Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each diagnosis-related group (DRG). Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs 24. The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment: ○ Confidential i. Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a clients examination, observation, conversation, or treatment with other clients or staff not involved in the clients care. The other options are primarily directed towards written records and are not ethically oriented. 25. Which of the following nursing statements regarding the release of a clients medical record to another institution requires immediate follow-up by the nurses manager? ○ The client agreed to the consultation, so Ill have the chart sent over. i. Each institution has policies to control the manner for sharing records. In most situations, clients are required to give written permission for release of medical information. The other options have the nurse asking for help or expressing doubt about the proper protocol for the release of the records; these would be appropriate statements and the manager should provide the correct information. 26. Regarding access to client records, the nursing faculty informs the nursing students to be prepared to: ○ Show the unit staff proper student identification i. When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, they obtain appropriate authorization according to agency policy. Nursing students and faculty may be required to present identification indicating access to the record is authorized. The remaining options are not required if the student is properly identified and shows a need to access the material. 27. Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care? ○ Notifying the client of the institutions privacy policy i. Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in order to eliminate barriers that could delay access to care, required only that health care providers notify clients of their privacy policy and make a reasonable effort to get written acknowledgment of this notification. 28. When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider, this is called a: ○ Referral i. Referrals are the request for services by another care provider usually for the purpose of determining appropriate client care. Consultations are a form of discussion whereby one professional caregiver actually gives formal advice about the care of a client to another caregiver. The remaining options are methods of exchanging general information regarding a client. 29. Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data? ○ Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists. i. Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objectively describe the noted client behavior. 30. Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data? ○ Client is depressed; was observed crying while alone in room i. Do not write personal opinions. Document observable, measurable client-oriented data only. Recording that the client is depressed based on the observation of tears is not objective and so is not acceptable. While one option does report only observable, measurable behavior, the remaining options, while noting observed client behavior, do fail to objectively describe the noted client behavior. 31. Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation? ○ I provided a detailed description of the dressing change in the clients chart in order to show it was done as prescribed i. Common charting mistakes that can result in malpractice include the following: (1) failing to record pertinent health or drug information; (2) failing to record nursing actions; (3) failing to record that medications have been given; (4) failing to record drug reactions or changes in clients condition; (5) writing illegible or incomplete records; and (6) failing to document a discontinued medication. Detailed descriptions of procedures are not included in the nursing notes. 32. The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a clients medical record is: ○ Linda Mozden, SN, Fairmont State University i. A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and educational institution, such as David Jones, SN (student nurse), CMTC (Central Maine Technical College) 33. The nurse realizes that the incorrect spelling of terms in the medical record most importantly: ○ Contributes to serious treatment errors i. Spelling errors can result in serious treatment errors; for example, the names of certain medications such as digitoxin and digoxin or morphine and Numorphan are similar. Misspelling such terms can result in medication errors that may cause serious harm to a client. The other options are correct but do not have the seriousness of client care errors. 34. Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem? ○ He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list i. New problems are added as they are identified. When a problem has been resolved, record the date and highlight it or draw a line through the problem and its number. Erasure is not an acceptable method of showing that a problem has been resolved. 35. Which of the following is an example of a problem statement used in the Problem- Intervention-Evaluation documentation method? ○ Risk for injury related to falling due to dizziness i. The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. 36. Which of the following is an example of an intervention used in the Problem-Intervention- Evaluation documentation method? ○ Educated to the purpose of dangling on the bedside before standing i. *Same explanation as Q 25 37. Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem? ○ He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list. i. New problems are added as they are identified. When a problem has been resolved, record the date and highlight it or draw a line through the problem and its number. Erasure is not an acceptable method of showing that a problem has been resolved. 38. Which of the following is an example of a problem statement used in the Problem- Intervention-Evaluation documentation method? ○ Risk for injury related to falling due to dizziness i. The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. 39. Which of the following is an example of an intervention used in the Problem-Intervention- Evaluation documentation method? ○ Educated to the purpose of dangling on the bedside before standing i. The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. 40. Nursing documentation should fulfill which of the following criteria? (Select all that apply.) ○ Accurate ○ Inclusive ○ Well Organized ○ Show continuity of care ○ Identify client outcomes i. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Nursing documentation should include nursing observations, not nursing opinions. 41. The nurse realizes that effective nursing documentation encourages: (Select all that apply.) ○ Safe nursing practice ○ Continuity of client care ○ Efficient time management i. Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors. While important, the remaining options are not criteria for effective nursing documentation. 42. Problem Oriented Medical Record (POMR) method of documentation includes which of the following sections? (Select all that apply.) ○ Database ○ Care plan ○ Problem list ○ Progress notes i. The POMR has the following major sections: database, problem list, care plan, and progress notes. Interventions and evaluations are documentation sections related to PIE (Problem, Interventions, and Evaluation) charting. 43. A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? ○ Sharing patient information with another student i. When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated, causing the preceptor to intervene. You can review your patients’ medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient’s medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit. 44. A nurse exchanges information with the oncoming nurse about a patient’s care. Which action did the nurse complete? ○ A verbal report i. Whether the transfer of patient information occurs through verbal reports, electronic or written documents, you need to follow some basic principles. Reports are exchanges of information among caregivers. A patient’s electronic medical record or chart is a confidential, permanent legal documentation of information relevant to a patient’s health care. Nurses document referrals (arrangements for the services of another care provider). Nurses use acuity ratings to determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours. 45. A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking? ○ Determining the degree to which standards of care are met by reviewing patients’ health records i. The auditing and monitoring of patients’ health records involve nurses periodically auditing records to determine the degree to which standards of care are met and identifying areas needing improvement and staff development. The mistakes in documentation that commonly result in malpractice include failing to record nursing actions; this is the aspect of legal documentation. The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient’s recorded findings to determine whether the new method was more effective than the standard protocol. Data analysis contributes to evidence-based nursing practice and quality health care. 46. After providing care, a nurse charts in the patient’s record. Which entry will the nurse document? ○ Skin pale and cool i. A factual record contains descriptive, objective information about what a nurse observes, hears, palpates, and smells. Objective data is obtained through direct observation and measurement (skin pale and cool). For example, “B/P 80/50, patient diaphoretic, heart rate 102 and regular.” Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as “Intake, 360 mL of water” is more accurate than “Patient drank an adequate amount of fluid.” 47. A nurse has provided care to a patient. Which entry should the nurse document in the patient’s record? ○ Left knee incision 1 inch in length without redness, drainage, or edema. i. Use of exact measurements establishes accuracy. Charting that an abdominal wound is “approximated, 5 cm in length without redness, drainage, or edema,” is more descriptive than “large abdominal incision healing well.” Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as “status unchanged” or “had good day.” It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. “Patient is hard to care for” is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, “refuses all treatments and medications.” 48. Which action by a novice nurse will cause the preceptor to provide follow up instructions? ○ Charts consecutively on every other line. i. Chart consecutively, line by line (not every other line); every other line is incorrect and must be corrected by the preceptor. If space is left, draw a line horizontally through it, and place your signature and credentials at the end. Every other line should not be left blank. All the other behaviors are correct and need no follow-up. Documenting should be as descriptive as possible. End each entry with signature and title/credentials. When recording subjective data, document a patient’s exact words within quotation marks whenever possible. 49. Which action can the nurse take legally when charting on a patient’s record? ○ Charts in a legible manner i. Record all entries legibly. Do not write personal opinions (belligerent). Enter only objective and factual observations of patient’s behavior; quote all patient comments. Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself. 50. A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse access? ○ Electronic health record i. The term electronic health record/EHR is increasingly used to refer to a longitudinal (lifetime) record of all health care encounters for an individual patient by linking all patient data from previous health encounters. An electronic medical record (EMR) is the legal record that describes a single encounter or visit created in hospitals and outpatient health care settings that is the source of data for the EHR. There are no such terms as electronic charting record or electronic problem record that record the lifetime information of a patient. 51. A nurse has instructed the patient regarding the proper use of 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? ○ Demonstrated use of crutches i. A second progress note method is the PIE format. The narrative note includes P—Nursing diagnosis, I—Intervention, and E—Evaluation. The intervention is “Demonstrated use of crutches.” “Patient went up and down stairs” and “Used crutches with no difficulties” are examples of E. “Deficient knowledge regarding crutches” is P. 52. A nurse wants to find the daily weights of a hospitalized patient. Which resource will the nurse consult? ○ Graphic record and flow sheet i. Within a computerized documentation system, flow sheets and graphic records allow you to quickly and easily enter assessment data about a patient, such as vital signs, admission and or daily weights, and percentage of meals eaten. In the problem-oriented medical record, the database section contains all available assessment information pertaining to the patient (e.g., history and physical examination, nursing admission history and ongoing assessment, physical therapy assessment, laboratory reports, and radiologic test results). Many computerized documentation systems have the ability to generate a patient care summary document that you review and sometimes print for each patient at the beginning and/or end of each shift; it includes information such as basic demographic data, health care provider’s name, primary medical diagnosis, and current orders. Health care team members monitor and record the progress made toward resolving a patient’s problems in progress notes. 53. 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? ○ Document the variance in the patient’s record i. A variance occurs when the activities on the critical pathway are not completed as predicted or the patient does not meet expected outcomes. An example of a negative variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A third format used for notes within a POMR is focus charting. It involves the use of DAR notes, which include D—Data (both subjective and objective), A—Action or nursing intervention, and R—Response of the patient (i.e., evaluation of effectiveness). 54. 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? ○ Upon admission i. Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals begin planning for discharge to the appropriate level of care, which sometimes includes support services such as home care and equipment needs. 55. A patient is being discharged home. Which information should the nurse include? ○ Community resources i. Discharge documentation includes medications, diet, community resources, follow-up care, and who to contact in case of an emergency or for questions. A patient’s acuity level, usually determined by a computer program, is based on the types and numbers of nursing interventions (e.g., intravenous [IV] therapy, wound care, or ambulation assistance) required over a 24-hour period. Many computerized documentation systems include standardized care plans or clinical practice guidelines (CPGs) to facilitate the creation and documentation of a nursing and or interprofessional plan of care. Each CPG facilitates safe and consistent care for an identified problem by describing or listing institutional standards and evidence-based guidelines that are easily accessed and included in a patient’s electronic health record. Verbal orders occur when a health care provider gives therapeutic orders to a registered nurse while they are standing in proximity to one another. 56. A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge ○ Mode of transportation i. List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. Clinical decision support systems (CDSSs) are computerized programs used within the health care setting, to aid and support clinical decision making. 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 that are presented to nurses as alerts, warnings, or other information for consideration. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style. 57. A home health nurse is preparing for an initial home visit. Which information should be included in the patient’s home care medical record? ○ Reports to third-party payers i. Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third-party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record. 58. A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing? ○ A minimum data set i. The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA), is the data set that is federally mandated for use in long-term care facilities by CMS. MDS assessment forms are completed upon admission, and then periodically, within specific guidelines and time frames for all residents in certified nursing homes. The MDS also determines the reimbursement level under the prospective payment system. A focused assessment is limited to a specific body system. An admission assessment and acuity level is performed in the hospital. An intake form is for home health. There is no such thing as an auditing phase in an assessment intake. 59. A nurse is charting. Which event is critical for the nurse to document? ○ The patient received a pain medication i. Nursing interventions and treatments (e.g., medication administration) must be documented. Avoid using generalized, empty phrases such as “status unchanged” or “had good day.” Do not document retaliatory or critical comments about a patient, like demanding and argumentative. Family is poor is not critical information to chart. 60. A nurse is completing an Outcome and Assessment Information Set (OASIS) data set on a patient. The nurse works in which area of patient care? ○ Home health i. Nurses use two different data sets to document the clinical assessments and care provided in the home care setting, the Outcome and Assessment Information Set (OASIS), and the Omaha System. The intensive care unit does not use the OASIS data set. The long-term health care setting includes skilled nursing facilities (SNFs) in which patients receive 24-hour day care. 61. A nurse is preparing to document a patient who has reported chest pain. Which information provided by the patient is critical for the nurse to include? ○ Reports sharp pain of 8 on a scale of 1 to 10 i. You need to ensure the information within a recorded entry or a report is complete, containing appropriate and essential information (pain of 8). Document subjective and objective assessment. While pupils equal and reactive to light is data, it does not relate to the chest pain; this information would be critical for a head injury. Derogatory or inappropriate comments about the patient or family is not appropriate. This kind of language can be used as evidence for nonprofessional behavior or poor quality of care. Avoid using generalized, empty phrases like “poor results.” Use complete, concise descriptions. 62. Which action will the nurse take when taking a telephone order? ○ Read back the order as written to the health care provider for verification. i. A read back of a telephone order is required and should contain all pertinent information so that verification can be secured. None of the other options provide verification of the details related to the order itself. 63. 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 pain. TO Dr. Day/J. Winds, RN, read back. i. 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 GRADESLAB.COM name and read back must be included in the chart entry. 64. A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up? ○ If a nurse has computer competency, the nurse is competent in informatics. i. 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. 65. 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? ○ Critical pathway design i. 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. 66. A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? ○ Chart on the computer immediately after care is provided. i. 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. 67. 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. Nurse call system 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 ○ 1830 i. 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. 2. A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? ○ Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. i. Accurately documenting services provided, including the supplies and equipment used in a patient’s care, clarifies the type of treatment a patient received. This documentation also supports accurate and timely reimbursement to a health care agency and/or patient. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as “status unchanged” or “had good day.” Do not enter personal opinions—stating that the patient is cooperative is a personal opinion and should be avoided. “Finally, patient had no complaints” is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care. 3. A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? ○ Home health, long-term care, and hospital nurses’ documentation can affect reimbursement for health care. i. Nurses’ documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. A “near miss” is an incident where no property was damaged and no patient or personnel were injured, but given a slight shift in time or position, damage or injury could have easily occurred. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA). 4. A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe ○ Reduce errors of omission i. Advantages associated with the nursing information system include reduced errors of omission; better access to information (not more time to read charts); enhanced quality of documentation; reduced, not increased, hospital costs; increased nurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database. 5. Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) ○ Gives a change-of-shift report to the oncoming nurse about the patient. ○ Reads the progress notes of assigned patient’s record. i. When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patient’s record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors that follow HIPAA and confidentiality guidelines. Do not share information with other patients or health care team members who are not caring for a patient. Not only is it unethical to view medical records of other patients, but breaches of confidentiality lead to disciplinary action by employers and dismissal from work or nursing school. To protect patient confidentiality, ensure that written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use. 6. A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.) ○ Communication ○ Legal documentation ○ Reimbursement ○ Research ○ Education i. A patient’s record is a valuable source of data for all members of the health care team. Its purposes include interdisciplinary communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record. 7. A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) ○ Implement an automatic sign-off. ○ Use a programmed speed-dial key when faxing. ○ Impose disciplinary actions for inappropriate access. ○ Shred papers containing personal health information (PHI). i. When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient’s name or address) must be destroyed immediately after you use or fax them. Most agencies have shredders or locked receptacles for shredding and incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed. 8. Fundamentals Ch. 36 - Loss and Grief 1. To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) ○ Previous experiences with grief and loss ○ Religious affiliation and denomination ○ Ethnic background and cultural practices 2. Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) ○ Allow the patient to determine timing and scheduling of interventions. ○ Allow patients to have visitors at any time. ○ Encourage the patient to eat whenever he or she is hungry i. Allowing patients to make choices about their care and end-of-life experience provides opportunities for them to maintain their autonomy 3. The nurse recognizes which factors influence a person’s approach to death? (Select all that apply.) ○ Culture ○ Spirituality ○ Personal beliefs ○ Previous experiences with death i. Culture, spirituality, personal beliefs and values, and previous experiences with death influence how a person approaches death 4. A nurse has the responsibility of managing a patient’s postmortem care. What is the proper order for postmortem care when there is no autopsy ordered? ○ 1. Ensure that the request for organ/tissue donation and/or autopsy was completed. ○ 2. Elevate the head of the bed. ○ 3. Collect any needed specimens. ○ 4. Speak to the family members about their possible participation. ○ 5. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. ○ 6. Remove all tubes and indwelling lines. ○ 7. Bathe the body of the deceased. ○ 8. Position the body for family viewing. ○ 9. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. i. This order provides dignity to the deceased and ensures that the nurse is adhering to all policies and laws concerning autopsies, organ donation, or an investigation 5. Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) ○ "Even though you're continuing treatment, palliative care is something we might want to talk about." ○ "Palliative care is appropriate for people with any diagnosis." ○ "Children are able to receive palliative care." i. Palliative care is available to all patients regardless of age, diagnosis, and prognosis. 6. A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in “hospice.” What does the nurse tell the family member about palliative care? (Select all that apply.) ○ Palliative care is for any patient, any time, any disease, in any setting. ○ Palliative care relieves the symptoms of illness and treatment. i. Palliative care and hospice care are different. Palliative care is available to all patients regardless of age, diagnosis, and prognosis. The focus of palliative care is on management of symptoms. 7. When planning care for a dying patient, which interventions promote the patient’s dignity? (Select all that apply.) ○ Providing respect ○ Viewing the patient as a whole ○ Showing interest ○ Being present i. A sense of dignity includes a person's positive self-regard, the ability to find meaning in life, to feel valued by others, and by how one is treated by caregivers. 8. What are the physical circulatory changes that occur as death approaches? ○ Mottling i. Patients experience circulatory changes resulting in mottling. Weakness, skin irritation, and incontinence are some of the physical changes that occur as death nears but are not related to circulatory changes. 9. When providing postmortem care, which actions are necessary for the nurse to complete? ○ Providing culturally and religiously sensitive care in body preparation i. A deceased person's body deserves the same respect and dignity as that of a living person and needs to be prepared in a manner consistent with the patient's cultural and religious beliefs 10. Which actions by the nurse help grieving families? (Select all that apply.) ○ Encourage involvement in non threatening group social activities. ○ Remind them that feelings of sadness or pain can return around anniversaries. ○ Encourage survivors to ask for help. ○ Look for overuse of alcohol, sleeping aids, or street drugs 11. A nurse encounters a family who experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child’s death. The nurse spends time with them discussing their child’s life and death. Which nursing principle does the nurse’s action best demonstrate? ○ Facilitation of a normal mourning i. Anniversary reactions can reopen grief processes. A nurse should openly acknowledge the loss and talk about the common renewal of grief feeling around the anniversary of the individual’s death; this facilitates normal mourning. The nurse is not attempting to