Test bank for essentials for nursing practice 9th edition by potter

Test Bank for Essentials for Nursing Practice 9th Edition By Potter

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Chapter 10: Informatics and Documentation Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. What is the best method for to The Joint Commission to demonstrate that it is assessing

quality patient care? a. Cost of care per patient day b. Number of registered nurses c. Absence of sentinel events d. Documentation audits ANS: D

Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require health care institutions to monitor and evaluate the quality and appropriateness of patient care. Typically, such monitoring and evaluations occur through the auditing of information health care providers document in patient records. It does not include cost of care per patient day, number of RNs, nor absence of sentinel events.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 2. The patient’s daughter requests to see the patient’s medical record. What is the nurse’s

appropriate response? a. “Come with me and we will look at it together.” b. “I’m sorry but that information is confidential.” c. “Let me ask my supervisor if it is okay.” d. “The doctor will have to give permission first.”

ANS: B

Nurses may not disclose information about patients’ status to other patients, family members unless specifically granted in writing by the patient. Looking at the medical record together is not acceptable because confidentiality would be broken. Asking a supervisor is inappropriate because the nurse should already know the legalities for confidentiality. The doctor does not give permission for the daughter to look at the patient’s medical records.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethical implications associated with documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 3. Which patient information may be included in the nursing student’s assignment that will

be turned in to the instructor after the clinical shift has ended? a. Room number b. Date of birth c. Medical record number

d. Nursing diagnosis ANS: D

The nursing diagnosis is acceptable information to give to a nursing instructor. To maintain confidentiality and protect patient privacy, instructors must make sure written materials used in student clinical practice do not have patient identifiers, such as room number, date of birth, medical record number, or other identifiable demographic information.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethical implications associated with documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 4. Which agency creates standards that require nursing documentation to be accurate, timely,

and patient-centered? a. Centers for Disease Control and Prevention b. World Health Organization c. The Joint Commission d. Agency for Healthcare Research and Quality ANS: C

The Joint Commission standard for record of care, treatment, and services requires that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning. Other standards include those directed by state and federal regulatory agencies such as HIPAA, as enforced through the Department of Justice, and the Centers for Medicare and Medicaid Services. The World Health Organization is concerned with international public health. The Centers for Disease Control and Prevention are concerned with the spread of infections. The Agency for Healthcare Research and Quality performs research to make health care safer for patients and providers.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 5. Which is the primary purpose of a patient’s medical record? a. To invoice the nursing services for hospital reimbursement b. To protect the patient in case of a malpractice suit c. To facilitate professional communication and safe health care d. To contribute to a worldwide databank for trends in health care ANS: C

The medical record helps to ensure that all health team members are working toward a common goal of providing safe and effective care. Documentation can be used for reimbursement but it is not to invoice the nurse, but to invoice patients and/or insurance companies. It protects the clinician in cases of a malpractice suit, not the patient. It does not contribute to a worldwide databank for trends in health care, but it can be used for medical or nursing research.

DIF: Cognitive Level: Understand (Comprehension)

OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 6. Which chart entry represents appropriate documentation about the patient’s pain

assessment? a. The patient appears not to be in any pain. b. The patient is sleeping comfortably. c. The patient always complains about being in pain. d. The patient rated the pain at 2 on a 0-to-10 scale.

ANS: D

States pain as 2 is factual. To be factual, avoid words such as appears, seems, or apparently because they are vague and lead to conclusions that cannot be supported by objective information.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 7. Which statement by the nurse accurately reflects a benefit of installing a new electronic

medical record system? a. “I am thankful that I won’t have to keep changing my passwords all the time.” b. “I’ll be able to see my son’s medical record using my password and user ID.” c. “I won’t have to worry about reading the doctor’s messy handwriting anymore.” d. “It will take me so much less time than writing everything out on paper.”

ANS: C

One of the main benefits of electronic medical record systems is that nurses and ancillary staff do not have to decipher illegibly written orders from providers. Electronic charting has not been shown to decrease documentation time. It will still be against HIPAA policy for the nurse to view family members’ medical records. Passwords must be changed regularly for all new electronic medical record system in order to maintain security of the documents.

DIF: Cognitive Level: Apply (Application) OBJ: Compare paper-based and electronic documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 8. Which chart entry reflects appropriate documentation of patient data? a. The patient voided a moderate amount of urine. b. The patient voided 220 mL of clear yellow urine. c. The patient was incontinent. d. The patient voided an adequate amount of urine for the shift.

ANS: B

The use of precise measurements makes documentation more accurate. For example, documenting “Voided 450 mL clear urine” is more accurate than “Voided an adequate amount.” Small and moderate are not as accurate as precise measurement. Patient incontinent of urine does not tell how much and although accurate is not as accurate as a precise measurement.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 9. Which is the correct military time entry for a medication that was administered at 8:30

p.m.? a. 0830 b. 140 c. 2030 d. 2230 ANS: B

The correct military time entry for 8:30 p.m. is 2030.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 10. The patient requests that her chart be destroyed as soon as she is discharged. What is the

best response of the nurse? a. “The hospital can give you the chart after you are discharged.” b. “Your chart will be kept secure and confidential.” c. “The information must be reported to the health department first.” d. “Your chart can be shredded if you give consent.”

ANS: B

The patient’s hospital record may not be destroyed after the patient is discharged. The patient should be reassured that all of the information in the record will be kept secure and confidential.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethical implications associated with documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 11. The nurse realizes that the wrong patient’s name was written on several important

paperwork forms that were already signed by the attending physician. How will the nurse correct this error? a. Black out the error with a thick marker and enter the correct information. b. Use correction tape to write over the incorrect information. c. Draw one line through the error, make the correction and initial it. d. Shred the forms with the incorrect information and write on new ones.

ANS: C

The nurse should make draw one line through the error, make the correction, and initial it so there is no attempt to cover up the mistake. The error should not be blacked out or covered with correction tape as it will hide the information. The forms should not be shredded as they were already signed by the physician. Agency policy may indicate the physician should initial each change as well.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 12. The patient was not able to continue along the migraine headache critical pathway after

suffering a stroke. Which terminology describes this deviation from the prescribed pathway? a. Negative variance b. Noncompliance with the treatment plan c. Risk-prone health behavior d. Care plan intolerance ANS: A

Any deviation from a critical pathway is termed a variance. A negative variance occurs when the patient develops a complication or new condition that leads to cessation or modification of the pathway. The patient did not demonstrate noncompliance with the treatment plan, risk-prone health behavior, or care plan intolerance.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 13. Before leaving at the end of the shift, the nurse realizes that a set of patient assessments

were taken earlier in the day but never charted. What is the appropriate action of the nurse? a. Enter the assessments in the chart the next day before receiving report. b. Do nothing because the other patient assessments were obtained during the shift. c. Direct the nursing assistant to enter the assessments into the patient’s chart. d. Enter the assessments into the chart as a late entry with a reason for the delay.

ANS: D

The nurse should enter the assessments into the chart as a late entry with a reason for the delay. The nurse should not wait until the next day to enter the assessments or do nothing with the information. The nursing assistant should never be directed to chart the nurse’s assessments.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethical implications associated with documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 14. The patient developed a large hematoma where the laboratory technician drew blood

earlier in the shift. Which statement is appropriate to enter in the patient’s chart? a. The laboratory technician did not know what he was doing and traumatized the

patient’s arm. b. The patient has a painful raised 2-inch  2-inch hematoma on the outer left arm after venipuncture. c. The laboratory technician must have had a hard time getting the blood sample drawn as the patient’s arm is now bruised. d. The patient must have moved during the blood draw because there is a huge bruise on his left arm.

ANS: B

Charting must be clear and factual without guesses or opinions. The patient has a painful raised 2-inch  2-inch hematoma on the outer left arm after venipuncture reflects objective documentation of the patient’s hematoma.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 15. After a patient fall, the supervisor asks the nurse to rewrite the entry in the patient’s chart

to show that the patient’s bed was lowered to the floor even though it was not. What is the best action of the nurse? a. Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. b. Remind the supervisor that it is against regulations to alter or falsify the patient’s chart. c. Ask the nurse assistant to chart that the patient’s bed was lowered to the floor at the time of the fall. d. Rewrite the entry as requested but note that the patient’s bed was not lowered to the floor in the incident report.

ANS: B

It is against regulations to alter or falsify the patient’s medical record regardless of the intent or desire to avoid a malpractice lawsuit. The nurse should never ask the nurse assistant to falsify information. The information in the incident report and patient chart should be factual and consistent.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethical implications associated with documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 16. Which entry in the patient’s chart will justify home nursing care reimbursement from

Medicare, Medicaid, and private insurance companies? a. The patient’s wound is improving slightly each day. b. The patient was receptive to the smoking cessation information. c. The patient’s family appreciated the nurse’s caring demeanor. d. The patient’s wound was 6 cm  4 cm and is now 4 cm  2 cm.

ANS: D

When you provide home care, your documentation must specifically address the category of care and your patient’s response to care. Receptive to teaching from the nurse and a gradually improving wound is not factual or objective information. Whether family liked the nurse or not does not affect reimbursement.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 17. Which action by the nurse minimizes the risk of unauthorized use of computer passwords

for the electronic medical record system? a. Using the same password for home and health care agency computers b. Writing each new computer password on the back of the name badge c. Periodically reusing previous computer passwords to prevent forgetting them d. Using passwords of at least eight characters with at least one number and symbol ANS: D

Passwords should have at least eight characters with at least one number and symbol.

Nurses should never use the same password for home and health care agency computers.

Nurses should have one designated password for work that should be changed every few months. Computer passwords should never be shared with anyone or written where they may be seen by others. Passwords should never be reused or recycled.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss methods for maintaining privacy and confidentiality of protected health information.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 18. Which information must be shared during the hand-off report to the oncoming nurse? a. The patient is nauseated and complaining of moderate generalized pain. b. The patient has six children and fourteen grandchildren. c. The patient will drink chicken broth but prefers to have lime gelatin. d. The patient sent back the dinner tray twice because the food was cold.

ANS: A

The hand-off information must communicate priority patient assessment data, changes in the patient’s condition, and any recent or anticipated changes to the treatment plan. The number of children and grandchildren in the patient’s family, clear liquid preferences, and returned dinner trays may be shared with the oncoming nurse but are not priorities.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 19. The nurse is working at a hospital whose electronic medical records system uses charting

by exception. Which entry would be appropriate to include in the narrative section of the patient’s chart? a. The patient voided 400 mL of clear yellow urine during the last 12 hours. b. The patient denies smoking, alcohol intake, or use of illicit substances.

c. The patient states that the pain level in his right knee is 7 on a 1-to-10 scale. d. The patient’s lung sounds are clear bilaterally with no cyanosis or dyspnea.

ANS: C

Charting by exception allows nurses to enter narrative notes only for assessment findings that are unusual, unexpected, or abnormal. Assessment findings that are expected or within normal limits may simply be checked off as such. The patient’s severe knee pain is outside of the normal limits and should be described using a narrative note.

DIF: Cognitive Level: Apply (Application) OBJ: Compare different methods and forms used for documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 20. The nurse fills out an incident report after a patient fall but makes no mention of the report

in the patient’s medical record. What is the reason for this? a. The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report. b. The incident report includes the nurse’s interpretations of what probably led the patient to get out of bed. c. A copy of the incident report is filed in the patient’s chart along with the nurse’s notes about the fall. d. The incident report is confidential and not intended to be used as evidence in a malpractice suit.

ANS: D

The incident report is never filed with the patient’s medical record. The incident report is used to facilitate investigation of the event within the agency. It is not intended to be part of the patient’s medical record as the findings of the investigation could potentially be used during a malpractice lawsuit. The incident report information should be factual without guesses or subjective interpretations. The presence of an incident report in the patient’s medical record would not lead to a malpractice lawsuit.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the purpose for incident (event, or occurrence) reports and why the existence of such reports should not be documented in the medical record.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 21. A nurse completes an incident/occurrence report after a patient fell. What is the reason for

this report? a. To compare patient fall rates between nursing units in the hospital b. To provide justification for the hospital to fire the nurse c. To prevent the patient from filing a malpractice lawsuit d. To aid in the hospital’s quality improvement program ANS: D

Incident reports are an important part of quality improvement. The overall goal is to identify changes needed to prevent future reoccurrence. A report is an exchange of information between health care members. Transfer reports involve communication of information about patients from one nurse on the sending unit to the nurse on the receiving unit. Occurrence reports do not prevent lawsuits. The nurse does not complete the incident report to provide cause for the nurse to be fired from the hospital.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the purpose for incident (event, or occurrence) reports and why the existence of such reports should not be documented in the medical record.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 22. What is the priority action of the nurse immediately after receiving a medication telephone

order from a physician? a. Withhold the medication until the physician signs the order. b. Authorize the physician’s order with the pharmacy. c. Read back the order to the physician for confirmation. d. Double-check the order with another registered nurse.

ANS: C

The nurse receiving a verbal order or telephone order writes down the complete order or enters it into the computer as it is being given. Then the nurse reads it back, called read-back, and receives confirmation from the person who gave the order. The medication will still be given because in most institutions the health care provider has 24 hours to sign the order. Verification is in the read-back with the person who ordered the medication, not with pharmacy or another nurse.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the relationship between informatics and quality health care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 23. Which statement exemplifies important patient information in the change-of-shift report? a. The patient sent his dinner tray back to the kitchen twice because the food was

cold. b. The patient keeps taking his nasal cannula off and threading it around the side rails

of the bed. c. The patient prefers to drink coffee that has cooled to room temperature with two

sugars and two creamers. d. The patient took all of the prescribed morning medications with a big glass of apple juice.

ANS: B

A change-of-shift report is a hand-off and provides information to ensure continuity and individualized care for patients. Important information should be communicated to make the most efficient use of the nurses’ time. The oncoming nurse must be told that the patient frequently takes off the nasal cannula as the patient may become hypoxemic. The other pieces of information are less important.

DIF: Cognitive Level: Apply (Application)

OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 24. Which specifics of care will be included in a patient’s critical pathway? a. Refer the patient to the outpatient cardiac rehabilitation program. b. Elevate the head of the patient’s bed to ease shortness of breath. c. Provide small meals throughout the day and encourage fluid intake. d. Teach the patient how to use relaxation techniques to ease shortness of breath.

ANS: A

Critical pathways are usually organized according to categories such as activity, diet, treatments, protocols, and discharge planning. The case-management plan incorporates critical pathways, which standardize practice and improve interdisciplinary coordination.

Referral of the patient to the outpatient cardiac rehabilitation program would be included in the critical pathway. Elevating the head of the patient’s bed, providing small meals, and teaching relaxation techniques would be considered independent nursing interventions that fall outside the realm of the critical pathway.

DIF: Cognitive Level: Apply (Application) OBJ: Compare different methods and forms used for documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 25. The nurse has just completed teaching the patient how to self-administer insulin injections.

Which entry in the patient’s chart demonstrates that the teaching was successful? a. The patient correctly self-administered his next scheduled dose of insulin. b. The patient denied having any questions or concerns about the procedure. c. Additional written instructions about how to perform the injection was provided. d. The patient identified the steps and equipment used for the injection.

ANS: A

Having the patient self-administer the next dose of insulin in front of the nurse will demonstrate competence and any areas that require reinforcement or correction. Asking the patient if there are any questions will not demonstrate competency as the patient may not be truthful about concerns. Providing additional written materials or identifying pieces of equipment will not demonstrate patient competency in the skill.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 26. The nurse is entering a note in the patient’s medical record using the SOAP format. Which

statement belongs in the Assessment section? a. The patient stated “I started feeling short of breath after smelling strong perfume.” b. The patient is using accessory muscles and has wheezes in all lung fields. c. Ineffective airway clearance related to exposure to environmental allergen. d. Monitor pulse oximetry and administer nebulized bronchodilators.

ANS: C

The Assessment section of the SOAP note describes the nurse’s assessment of the situation, usually in the form of a nursing diagnosis such as ineffective airway clearance.

The patient’s feelings of dyspnea belong in the Subjective information section of the note.

The patient’s wheezes and use of accessory muscles belongs in the Objective section of the note. Monitoring pulse oximetry and administering bronchodilators belongs in the Plan section of the note.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Compare different methods and forms used for documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 27. At the nursing station, the nurse receives a verbal order from the physician for a routine

medication. What is the best action of the nurse? a. Request that the doctor enter the order into the computer. b. Repeat the order to the doctor and enter it into the computer. c. Direct the unit secretary to enter the order into the computer. d. Call the pharmacy to determine that the drug dosage is appropriate.

ANS: A

Verbal orders should only be used when absolutely necessary such as patient emergencies.

They should never be used for the physician’s convenience. The nurse should direct the physician to enter the order into the computer to minimize the risk of an error. The nurse should not enter the order into the computer or direct the unit secretary to do it. Calling the pharmacy to determine the drug dosage may be done after the physician has entered the order into the computer.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the relationship between informatics and quality health care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. Which information must be included in the patient’s discharge summary? (Select all that

apply.) a. The patient is to follow up with the primary care physician in 14 days. b. The patient arrived at the hospital by ambulance with acute shortness of breath. c. Supplemental oxygen was administered to the patient in the emergency room. d. The patient is to have a protime (PT) level drawn daily for the next 7 days. e. The patient is to take the prescribed antibiotic daily even after symptoms subside ANS: A, D, E

The discharge summary should include directions for medications, follow-up appointments with physicians, and ongoing laboratory testing. The patient’s condition on arrival to the hospital and emergency treatment do not need to be included.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe guidelines for effective documentation in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care

Test Bank for Essentials for Nursing Practice 9th Edition By Potter

2. The nurse is caring for a patient who climbed out of bed and fell on the floor. What will

the nurse do in regard to the incident report? (Select all that apply.) a. Document how the patient was found and a description of the injuries. b. Include recommendations for future fall prevention interventions. c. Note in the patient’s chart that an incident report was completed. d. Indicate that the nursing assistant wasn’t doing her job correctly. e. Document fall prevention steps that were in place before the patient fell.

ANS: A, E

The nurse should document exactly how the patient was found and a description of the injuries using clear, objective terms. Subjective or judgmental statements about other staff members are never included. Any fall prevention steps that were in place before the patient fell should be included as well. Recommendations for future fall prevention interventions are not included in the incident report. No mention of the incident report is included in the patient’s medical record.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the purpose for incident (event, or occurrence) reports and why the existence of such reports should not be documented in the medical record.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 3. Which patient situations require the completion of an incident report? (Select all that

apply.) a. A patient almost receives the wrong medication due to unclear wording on the packaging from the pharmacy. b. A patient repeatedly refuses to eat food from the hospital kitchen because it is always too salty or too cold. c. A visitor trips on an icy sidewalk in the hospital parking lot and suffers a fractured wrist. d. The nurse accidentally enters the wrong vital signs into the patient’s medical record and corrects the error shortly afterward. e. The patient dislikes male nursing staff and prefers to have only female nurses providing personal care.

ANS: A, C

Near misses such as medication errors that almost occurred should be documented with an incident report to help prevent the same problem from recurring in the future. Mishaps by visitors, vendors, or staff should always be documented in incident reports as well. Patient preferences for nursing care and food do not require incident reports. An incident report should not be completed if the nurse corrected the computer entry appropriately and there was no adverse impact on patient care.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the purpose for incident (event, or occurrence) reports and why the existence of such reports should not be documented in the medical record.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care

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