(T/F) The patient's record is accessible to all health care professionals, regardless of involvement in patient's care - correct answer False
(T/F) If a page of your nurse's notes becomes soiled, you must discard the page after recopying any data - correct answer False: keep damaged page in the ...
(T/F) The patient's record is accessible to all health care professionals, regardless of involvement in
patient's care - correct answer ✔✔False
(T/F) If a page of your nurse's notes becomes soiled, you must discard the page after recopying any data
- correct answer ✔✔False: keep damaged page in the chart; make a notation on damaged page
indicating the page will be rewritten and reference to the recopied page, on new page: write 'recopied
from page *', and include current date/time/signature
(T/F) Avoid trying to 'write over' incorrect letters in entries - correct answer ✔✔True
(T/F) The nurse (you) is not authorized to write verbal orders of the Physician; eg: treatments/meds/diet
orders - correct answer ✔✔False
A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry,
"Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following
directions does the manager give to the staff nurse who entered the note?
-Avoid rushing when charting an entry.
-Use correction fluid to remove the entry.
-Draw a single line through the statement and initial it.
-Enter only objective and factual information about the pt. - correct answer ✔✔Enter only objective and
factual information about the pt.
A new graduate nurse is providing a telephone report to a patient's health care provider and accepting
telephone orders from the provider. Which of the following actions requires the new nurse's preceptor
to intervene? The new nurse:
-Uses SBAR (Situation-Background-Assessmt-Recommendation) as a format when providing the report.
-Gives a newly ordered medication before entering the order in the patient's medical record.
-Reads the orders back to the health care provider after receiving them and verifies their accuracy.
,-Asks the preceptor to listen in on the phone conversation. - correct answer ✔✔Gives a newly ordered
medication before entering the order in the patient's medical record.
As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I
don't know what's going on; I can't get an explanation from my doctor about my test results. I want
something done about this." Which of the following is the most appropriate documentation of the pt's
emotional status?
-The pt has a defiant attitude and is demanding his test results.
-The pt appears to be upset with his nurse because he wants his test results immediately.
-The pt is demanding and complains frequently about his doctor.
-The pt stated that he felt frustrated by the lack of information he received regarding his tests. - correct
answer ✔✔The pt stated that he felt frustrated by the lack of info he received regarding his tests.
A pt asks for a copy of her medical record. The best response by the nurse is to:
-State that only her family may read the record.
-Indicate that she has the right to read her record.
-Tell her that she is not allowed to read her record.
-Explain that only health care workers have access to her record. - correct answer ✔✔Indicate that she
has the right to read her record.
On the nursing unit you are able to access a pt's medical record and review the education that other
nurses provided to the pt during an initial hospitalization and three subsequent clinic visits. This type of
feature is most common in what type of record system?
-Information technology
-Electronic health record
-Personal health information
-Administrative information system - correct answer ✔✔Electronic health record.
You are having a hand-off report to another nurse who will be caring for your pt at the end of your shift.
Which of the following pieces of information do you include in the report? (Select all that apply).
-The pt's name, age, and admitting diagnosis.
-Allergies to food and medications
, -Your evaluation that the pt is "needy"
-How much the pt ate for breakfast
-That the pt's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol. -
correct answer ✔✔-Allergies to food and medications
-That the pt's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol.
You are supervising a beginning nursing student who is documenting pt care. Which of the following
actions requires you to intervene? The nursing student:
-Documented medication given by another nursing student.
-Included the date and time of all entries in the chart.
-Stood with his back against the wall while documenting on the computer.
-Signed all documentation electronically. - correct answer ✔✔Documented medication given by another
nursing student.
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE).
Which of the following statements indicates that the nurses understand the major advantage of using
CPOE?
-CPOE reduces transcription errors
-CPOE reduces the time necessary for health care providers to write orders.
-Health care providers can write orders from any computer that has Internet access.
-CPOE reduces the time nurses use to communicate with health care providers. - correct answer
✔✔CPOE reduces transcription errors.
Which of the following should the nurse include in an intershift report to nursing colleagues?
-The client's diagnostic-related group
-All routine care procedures required by the client
-Audit of client care procedures
-Instructions given to the client in a teaching plan - correct answer ✔✔Instructions given to the client in
a teaching plan
The correct reporting of an incident involves which of the following:
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