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Which information in a patient's electronic medical record
(EMR), in addition to nursing flowsheets and provider orders,
helps a nurse plan and manage fluctuations in blood glucose
levels?
a. Medication Administration Record (MAR)
b. Radiology reports
c. Admission history and physical
d. Discharge planning notes
e. Consultation notes
✔️ Correct Answer: A
Rationale:
The Medication Administration Record (MAR) is essential for
planning and managing blood glucose fluctuations because it
provides information about when insulin and other glucose-
,lowering medications were administered, along with dosages
and routes. Option A is correct because the MAR allows the
nurse to correlate medication administration with blood glucose
trends. Option B, radiology reports, do not provide glucose-
related information. Option C, admission history and physical,
provides baseline information but not real-time medication
data. Option D, discharge planning notes, are not directly
relevant to immediate glucose management. Option E,
consultation notes, contain recommendations but not the
medication administration data needed for glucose
management. The MAR is a critical tool for medication
reconciliation and glycemic control monitoring.
A nurse is planning care for a patient admitted to the hospital
with COVID-19. Which information in the electronic medical
record (EMR) will help the nurse plan care for this patient?
a. The patient's laboratory results over the last 72 hours
b. The patient's transfer location history since admission
c. The hospital services covered by the patient's health
insurance
d. The nurses who provided care in the emergency department
e. The patient's dietary preferences
✔️ Correct Answer: A
Rationale:
Laboratory results over the last 72 hours are essential for
,planning care for a COVID-19 patient because they provide
critical information about disease progression, including oxygen
saturation, inflammatory markers, and organ function. Option A
is correct because these results inform clinical decision-making.
Option B, transfer location history, is less relevant to direct care
planning. Option C, insurance coverage, is administrative.
Option D, nursing assignment history, does not inform clinical
care. Option E, dietary preferences, is secondary to the acute
medical needs. COVID-19 care planning requires continuous
monitoring of laboratory values to assess response to treatment
and identify deterioration.
Which clinical note type is exempt from being shared with
patients according to the United States Core Data for
Interoperability (USCDI) standards?
a. Imaging notes
b. Pathology notes
c. Progress notes
d. Psychotherapy notes
e. Discharge summary notes
✔️ Correct Answer: D
Rationale:
Psychotherapy notes are exempt from being shared with
patients under USCDI standards because they contain sensitive
mental health information that may be harmful if disclosed
, without appropriate context. Option D is correct because the
21st Century Cures Act allows for the exclusion of
psychotherapy notes from the mandatory sharing requirement.
Option A, imaging notes, must be shared. Option B, pathology
notes, must be shared. Option C, progress notes, must be
shared. Option E, discharge summary notes, must be shared.
This exemption balances the benefits of information sharing
with the need to protect particularly sensitive mental health
information.
Operating room (OR) staff are reliant upon a manual
whiteboard for patient tracking. Recently, surgeons have
complained that the turnaround time between surgical cases
has increased and blame the manual tracking system. An
informatics nurse recommends expanding the use of the
existing surgical information system (SIS). Which resolution can
improve this workflow issue?
a. Radiofrequency identification (RFID) in patient labels
b. Switching to electronic boards for operating rooms
c. Giving mobile communication devices to staff
d. Hiring additional staff dedicated to workflow management
e. Implementing a paper-based tracking system
✔️ Correct Answer: B
Rationale:
Switching to electronic boards for operating rooms would