N150A Week 6: Informatics & Documentation Exam
With Complete Solutions
Which key element must nurses understand about the electronic health record (EHR)?
a) It was developed to create a safe, secure environment for patient data
b) It was developed to complement a paper chart
c) It was developed to help meet government regulations
d) It was developed to be a data storage system - answer a) It was developed to create a
safe, secure environment for patient data
Match the electronic health record benefit with the example.
Example:
- Nurse getting patient data from mobile device
- Patient checks his/her blood sugar result
- Electronic care instructions
- Connectivity to all hospital systems
EHR Benefit:
- Convenient access to patient records
- Discharge planning
- Electronic health record (EHR) system interface
- Self-participation in care - answer Nurse getting patient data from mobile device -->
Convenient access to patient records
Patient checks his/her blood sugar result --> Self-participation in care
Electronic care instructions --> Discharge planning
,Connectivity to all hospital systems --> Electronic health record (EHR) system interface
The nurse is caring for a patient admitted to the unit with a cough and fever. Which
example illustrates enhanced decision support as a benefit of the electronic health
record?
a) Taking action based on rapid blood sugar test results
b) Accessing patient data from a mobile device
c) Accessing a chest x-ray and laboratory results for a patient with breathing difficulty
d) Providing electronic copies of discharge prescriptions - answer a) Taking action
based on rapid blood sugar test results
--> the interface with point-of-care testing and access to hospital systems, such as the
laboratory and radiology, facilitate a nurse's ability to plan appropriate patient care
The nurse is caring for an older adult patient with diabetes. Which statements identify
the use of key documentation standards developed by the American Nurses Association
(ANA)? Select all that apply.
a) The nurse documents the patient's diabetes medication administration in the
electronic Medication Administration Record (eMAR)
b) The nurse logs out of the computer after entering patient information and data
c) The nurse documents the patient's blood sugar per prescriptions 2 hours after
breakfast
d) The nurse documents his or her thoughts about what medications the patient should
be taking because the patient's blood sugar is elevated
e) The nurse documents the patient assessment in his or her own words to better
describe the patient's needs - answer a) The nurse documents the patient's diabetes
medication administration in the electronic Medication Administration Record (eMAR)
b) The nurse logs out of the computer after entering patient information and data
c) The nurse documents the patient's blood sugar per prescriptions 2 hours after
breakfast
The nurse is caring for a patient with hypertension, frequently taking the patient's blood
, pressure, and documenting it in the electronic health record. Blood pressure is an
example of which type of data?
a) Objective data
b) Subjective data
c) Care-planning data
d) Outcome data - answer a) Objective data
Match the type of documentation error to its probable result.
Probable Result:
- Inappropriate order of care
- Missing medication dose
- Misinterpretation
- Patient care not validated
Type of Documentation Error:
- Erroneous abbreviation
- Lack of clarity
- Late entry
- Omission - answer Inappropriate order of care --> Late entry
Missing medication dose --> Omission
Misinterpretation --> Erroneous abbreviation
Patient care not validated --> Lack of clarity
With Complete Solutions
Which key element must nurses understand about the electronic health record (EHR)?
a) It was developed to create a safe, secure environment for patient data
b) It was developed to complement a paper chart
c) It was developed to help meet government regulations
d) It was developed to be a data storage system - answer a) It was developed to create a
safe, secure environment for patient data
Match the electronic health record benefit with the example.
Example:
- Nurse getting patient data from mobile device
- Patient checks his/her blood sugar result
- Electronic care instructions
- Connectivity to all hospital systems
EHR Benefit:
- Convenient access to patient records
- Discharge planning
- Electronic health record (EHR) system interface
- Self-participation in care - answer Nurse getting patient data from mobile device -->
Convenient access to patient records
Patient checks his/her blood sugar result --> Self-participation in care
Electronic care instructions --> Discharge planning
,Connectivity to all hospital systems --> Electronic health record (EHR) system interface
The nurse is caring for a patient admitted to the unit with a cough and fever. Which
example illustrates enhanced decision support as a benefit of the electronic health
record?
a) Taking action based on rapid blood sugar test results
b) Accessing patient data from a mobile device
c) Accessing a chest x-ray and laboratory results for a patient with breathing difficulty
d) Providing electronic copies of discharge prescriptions - answer a) Taking action
based on rapid blood sugar test results
--> the interface with point-of-care testing and access to hospital systems, such as the
laboratory and radiology, facilitate a nurse's ability to plan appropriate patient care
The nurse is caring for an older adult patient with diabetes. Which statements identify
the use of key documentation standards developed by the American Nurses Association
(ANA)? Select all that apply.
a) The nurse documents the patient's diabetes medication administration in the
electronic Medication Administration Record (eMAR)
b) The nurse logs out of the computer after entering patient information and data
c) The nurse documents the patient's blood sugar per prescriptions 2 hours after
breakfast
d) The nurse documents his or her thoughts about what medications the patient should
be taking because the patient's blood sugar is elevated
e) The nurse documents the patient assessment in his or her own words to better
describe the patient's needs - answer a) The nurse documents the patient's diabetes
medication administration in the electronic Medication Administration Record (eMAR)
b) The nurse logs out of the computer after entering patient information and data
c) The nurse documents the patient's blood sugar per prescriptions 2 hours after
breakfast
The nurse is caring for a patient with hypertension, frequently taking the patient's blood
, pressure, and documenting it in the electronic health record. Blood pressure is an
example of which type of data?
a) Objective data
b) Subjective data
c) Care-planning data
d) Outcome data - answer a) Objective data
Match the type of documentation error to its probable result.
Probable Result:
- Inappropriate order of care
- Missing medication dose
- Misinterpretation
- Patient care not validated
Type of Documentation Error:
- Erroneous abbreviation
- Lack of clarity
- Late entry
- Omission - answer Inappropriate order of care --> Late entry
Missing medication dose --> Omission
Misinterpretation --> Erroneous abbreviation
Patient care not validated --> Lack of clarity
