DAVIS ADVANTAGE CH 17
DOCUMENTING AND REPORTING
EXAM QUESTIONS AND ANSWERS
What are disadvantages of charting by exception?
SELECT ALL THAT APPLY
A. It requires nurses to be overly familiar with an organization's documentation
standards
B. It is difficult to capture the skilled judgment of nurses
C. It is very cumbersome and time consuming to use
D. It can lead to errors because nurses may conclude that care has been done when
it has not
E. It results in repeat work when interventions or assessment findings are
documented in multiple places - ANSWER-A,B,D
Which are examples of appropriate medication orders for an inpatient?
SELECT ALL THAT APPLY
A. Lasix by mouth twice daily
B. Aspirin 325 mg by mouth every morning
C. Tylenol 500 mg prn
D. Rocephin 200 mg IV q6h
E. Ibuprofen 200 mg q4h prn fever or mild pain - ANSWER-B,D
Which are ways health providers use documentation to provide quality care?
SELECT ALL THAT APPLY
A. Communication tool
B. Continuity of care
C. Shift report
D. Communication with family members
E. Legal record - ANSWER-A,B,E
What should be considered when using abbreviations in nursing documentation?
A. It is acceptable to use common abbreviations in all documentation
B. Abbreviations should never be used in documentation
C. Each facility should have a list of approved abbreviations
D. Every medical record should have a reference to identify the meaning of any
abbreviations - ANSWER-C
How does the nurse maintain confidentiality and privacy when using an electronic
health record (EHR)?
SELECT ALL THAT APPLY
A. By never sharing their username or password
B. By regularly changing their password
C. By leaving the clients chart displayed inside client rooms only
D. By accessing records of past and current clients
E. By permanently logging off the systems when leaving an EHR - ANSWER-A,B,E
DOCUMENTING AND REPORTING
EXAM QUESTIONS AND ANSWERS
What are disadvantages of charting by exception?
SELECT ALL THAT APPLY
A. It requires nurses to be overly familiar with an organization's documentation
standards
B. It is difficult to capture the skilled judgment of nurses
C. It is very cumbersome and time consuming to use
D. It can lead to errors because nurses may conclude that care has been done when
it has not
E. It results in repeat work when interventions or assessment findings are
documented in multiple places - ANSWER-A,B,D
Which are examples of appropriate medication orders for an inpatient?
SELECT ALL THAT APPLY
A. Lasix by mouth twice daily
B. Aspirin 325 mg by mouth every morning
C. Tylenol 500 mg prn
D. Rocephin 200 mg IV q6h
E. Ibuprofen 200 mg q4h prn fever or mild pain - ANSWER-B,D
Which are ways health providers use documentation to provide quality care?
SELECT ALL THAT APPLY
A. Communication tool
B. Continuity of care
C. Shift report
D. Communication with family members
E. Legal record - ANSWER-A,B,E
What should be considered when using abbreviations in nursing documentation?
A. It is acceptable to use common abbreviations in all documentation
B. Abbreviations should never be used in documentation
C. Each facility should have a list of approved abbreviations
D. Every medical record should have a reference to identify the meaning of any
abbreviations - ANSWER-C
How does the nurse maintain confidentiality and privacy when using an electronic
health record (EHR)?
SELECT ALL THAT APPLY
A. By never sharing their username or password
B. By regularly changing their password
C. By leaving the clients chart displayed inside client rooms only
D. By accessing records of past and current clients
E. By permanently logging off the systems when leaving an EHR - ANSWER-A,B,E
