NUR 112 Exam 1 Questions With Correct
Answers
Elements of Documentation (Guidelines) - CORRECT ANSWER✔✔--
| | | | | |
accessible
|
- accurate
|
- relevant
|
- consistent
|
- auditable
|
- clear
|
- concise/ complete
| |
- legible/readable
|
-thoughtful
- timely
|
- sequential
|
- reflective of the nursing process
| | | | |
- retrievable on a permanent basis in a nursing- specific manner.
| | | | | | | | | |
,Who should document? - CORRECT ANSWER✔✔-Whoever is
| | | | | |
responsible for the nurses care should chart but others can chart in as
| | | | | | | | | | | | |
well. Everyone should document!!!
| | | |
Why should you document without error? - CORRECT ANSWER✔✔-Poor
| | | | | | | |
documentation can be presumed as medical negligence. "CYA".
| | | | | | | |
Make sure you're documenting without error/ i.e. Don't document the
| | | | | | | | |
wrong BP. Can possibly affect medication dosage.
| | | | | | |
Errors make nurses look less credible. Which can affect credibility.
| | | | | | | | |
What is informatics? - CORRECT ANSWER✔✔-computer and software
| | | | | | |
systems (may include pager system any type of tech)
| | | | | | | | |
Should you skip lines if you're charting? - CORRECT ANSWER✔✔-No!
| | | | | | | | |
Approved abreviations - CORRECT ANSWER✔✔-A.C.- Before meals
| | | | | |
b.i.d.- twice a day | | |
c - with
| |
D/C- discontinue or discharge
| | |
gtt, GTT- drops
| |
IVPB- intravenous piggyback
| |
mg-milligram
,mcg- microgram |
O.D.- right eye | |
O.S.- left eye | |
O.U.- both eyes | |
P- after
|
p.c.- after meals
| |
PRN, p.r.n.- as needed
| | |
P.O., p.o.- by mouth
| | |
p.r., R- rectally
| |
q.h.- every hour| |
q.i.d.- four times a day | | | |
QS- quantity sufficient
| |
s- without
|
ss- one-half
|
t.i.d.- three times a day
| | | |
What is HIPAA - CORRECT ANSWER✔✔-Health Insurance Portability and
| | | | | | | |
Accountability Act
| |
Potential Breaches in Patient Confidentiality - CORRECT ANSWER✔✔-
| | | | | | |
Displaying information on a public screen | | | | |
, -Sending confidential e-mail messages via public networks
| | | | | |
-Sharing printers among units with differing functions
| | | | | |
-Discarding copies of patient information in trash cans
| | | | | | |
-Holding conversations that can be overheard
| | | | |
-Faxing confidential information to unauthorized persons
| | | | |
-Sending confidential messages overheard on pagers
| | | | |
Hypothetically, if a patient had yellow skin, was not wearing pants, was
| | | | | | | | | | |
smiling, and its stomach is sticking out, and the patient also states, "I'm
| | | | | | | | | | | | |
rumbly in my tummly." How would you chart this? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-Patient has generalized jaundice. Ambulating in room.
| | | | | | |
Patient is not wearing pants. Protruding abdomen. The patient is
| | | | | | | | | |
smiling. No signs of distress. Patient states I'm rumbly in my tummy.
| | | | | | | | | | | |
Patient "I'm hungry".
| | |
Patient's have the right to: - CORRECT ANSWER✔✔--See and copy their
| | | | | | | | | |
health record
| |
-Update their health record
| | |
-Get a list of disclosures
| | | |
-Request a restriction on certain uses or disclosures
| | | | | | |
-Choose how to receive health information
| | | | |
Answers
Elements of Documentation (Guidelines) - CORRECT ANSWER✔✔--
| | | | | |
accessible
|
- accurate
|
- relevant
|
- consistent
|
- auditable
|
- clear
|
- concise/ complete
| |
- legible/readable
|
-thoughtful
- timely
|
- sequential
|
- reflective of the nursing process
| | | | |
- retrievable on a permanent basis in a nursing- specific manner.
| | | | | | | | | |
,Who should document? - CORRECT ANSWER✔✔-Whoever is
| | | | | |
responsible for the nurses care should chart but others can chart in as
| | | | | | | | | | | | |
well. Everyone should document!!!
| | | |
Why should you document without error? - CORRECT ANSWER✔✔-Poor
| | | | | | | |
documentation can be presumed as medical negligence. "CYA".
| | | | | | | |
Make sure you're documenting without error/ i.e. Don't document the
| | | | | | | | |
wrong BP. Can possibly affect medication dosage.
| | | | | | |
Errors make nurses look less credible. Which can affect credibility.
| | | | | | | | |
What is informatics? - CORRECT ANSWER✔✔-computer and software
| | | | | | |
systems (may include pager system any type of tech)
| | | | | | | | |
Should you skip lines if you're charting? - CORRECT ANSWER✔✔-No!
| | | | | | | | |
Approved abreviations - CORRECT ANSWER✔✔-A.C.- Before meals
| | | | | |
b.i.d.- twice a day | | |
c - with
| |
D/C- discontinue or discharge
| | |
gtt, GTT- drops
| |
IVPB- intravenous piggyback
| |
mg-milligram
,mcg- microgram |
O.D.- right eye | |
O.S.- left eye | |
O.U.- both eyes | |
P- after
|
p.c.- after meals
| |
PRN, p.r.n.- as needed
| | |
P.O., p.o.- by mouth
| | |
p.r., R- rectally
| |
q.h.- every hour| |
q.i.d.- four times a day | | | |
QS- quantity sufficient
| |
s- without
|
ss- one-half
|
t.i.d.- three times a day
| | | |
What is HIPAA - CORRECT ANSWER✔✔-Health Insurance Portability and
| | | | | | | |
Accountability Act
| |
Potential Breaches in Patient Confidentiality - CORRECT ANSWER✔✔-
| | | | | | |
Displaying information on a public screen | | | | |
, -Sending confidential e-mail messages via public networks
| | | | | |
-Sharing printers among units with differing functions
| | | | | |
-Discarding copies of patient information in trash cans
| | | | | | |
-Holding conversations that can be overheard
| | | | |
-Faxing confidential information to unauthorized persons
| | | | |
-Sending confidential messages overheard on pagers
| | | | |
Hypothetically, if a patient had yellow skin, was not wearing pants, was
| | | | | | | | | | |
smiling, and its stomach is sticking out, and the patient also states, "I'm
| | | | | | | | | | | | |
rumbly in my tummly." How would you chart this? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-Patient has generalized jaundice. Ambulating in room.
| | | | | | |
Patient is not wearing pants. Protruding abdomen. The patient is
| | | | | | | | | |
smiling. No signs of distress. Patient states I'm rumbly in my tummy.
| | | | | | | | | | | |
Patient "I'm hungry".
| | |
Patient's have the right to: - CORRECT ANSWER✔✔--See and copy their
| | | | | | | | | |
health record
| |
-Update their health record
| | |
-Get a list of disclosures
| | | |
-Request a restriction on certain uses or disclosures
| | | | | | |
-Choose how to receive health information
| | | | |
