Which data in a medical record would inform the nurse that a PRN pain medication can be
administered to the patient? correct answers The medication administration record and the
nursing assessment notes from the last shift indicate the patient's level of comfort.
Which information in a patient's medical record will help a nurse plan and manage the patient's
pain? correct answers Physician orders
A patient completes the course of treatment for tuberculosis and is ready to be discharged home.
Which instructions should be included in the patient's discharge education? correct answers
Importance of completing the medication prescribed
A mother brings her child to the emergency department after noticing the child had trouble
breathing, refused breastfeeding, and no urine in the diaper within the last eight hours. The
provider suspects respiratory syncytial virus and admits the infant to the hospital. How will data
in the medical record inform the decision to select appropriate infection-control precautions?
correct answers The data will identify the pathogen causing the patient's symptoms
A nurse admits an infant with a severe, hacking cough who is vomiting and who has had a fever
for the past two weeks. Which data in the electronic health record (EHR) informs the decision to
implement infection-control precautions? correct answers The nasopharyngeal swab culture
results indicate the patient is positive for Bordetella pertussis.
A patient is admitted to the hospital with a painful rash on the left side of the face. The provider
orders the patient to be placed on contact precautions. Which data in the electronic health record
(EHR) informed the decision to implement contact precautions? correct answers The skin culture
results indicate the presence of the varicella-zoster virus.
After a patient's assessment, a nurse observes a decrease in respiration and wheezing on
auscultation. Which data set in the medical record informs the decision to implement the
ineffective airway clearance nursing care plan? correct answers The complete health history and
allergy list indicate a history of asthma and seasonal allergies.
, The health administrator at a clinic observes an increase in the number of patients with a
complaint of difficulty breathing, fatigue, and loss of appetite. Which data in the electronic
health record (EHR) will provide a cross-reference to the impacted patient population? correct
answers Patient demographic records
Which view in the electronic health record (EHR) confirms a patient's blood pressure is
stabilizing? correct answers Graphical trending
After a patient's initial assessment, a nurse observes an increase in edema, bilateral crackles, and
persistent cough. Which data set in the medical record from the last shift informs the decision to
implement the fluid volume overload care plan? correct answers Nursing flowsheet and intake
and output record
Which data set in the electronic health record (EHR) will assist in evaluating the number of
positive influenza tests at a facility within the past year? correct answers Laboratory records
During the evening shift, a nurse notices a significant change in a patient's blood pressure as
compared to the morning shift. Which 24-hour trend information in the electronic health record
(EHR) will help the nurse further evaluate and manage the patient's blood pressure? correct
answers The intake and output record
Pharmacy adds a field into the medication administration record to document the lot number
when a chemo medication is administered, but fails to communicate this to the nurse responsible
for the medication administration documentation. What is a consequence of this action? correct
answers Pharmacy cannot determine if there is a problem with a medication batch.
A nurse thinks the electronic health record (EHR) has too many documentation fields, making it
difficult to know where to document some items. As a result, the nurse uses the notes instead or
in addition to documenting in a specific field in the health record. What is the least significant
impact of this action? correct answers Duplicate documentation appears multiple times in the
chart.