nurse is member of interdisciplinary team that uses critical pathways on day 2 of hospital stay the pt should be sitting

document the variance in the pts record

nurse is providing care to group of pts. which situation will require nurse to obtain telephone order?

at 0100 pts BP drops from 120/80 to 90/50 and incision dressing is sat.

nurse is auditing & monitoring pts health records. which action is the nurse taking?

determining the degree to which standards of care are met by reviewing pt r

nurse is teaching staff about health care reimbursement. which info should nurse include in teaching lesson?

home health, long term care, and hospital nurses documentation can affect r

preceptor is working with a new nurse on documentation. which situation will call preceptor f/u

new nurse charts consecutively on every other line

nurse is charting. which info is critical for the nurse to document?

pt recorda pain medication, Lortab

nurse is teaching staff about informatics. which info from the staff indicates the nurse needs to f/u?

if a nurse has computer competency, nurse is competent in informatics

nurse had provided care to a pt. which entry should nurse document in the pts record

left knee incision 1 inch in length w/o redness, drainage, edema

pt with dx of PNA. which entry should nurse chart to help with financial aid?

uses incentive spirometer to encourage coughing. lung congested upon auscul

a nurse preceptor working with student nurse. which behavior by student nurse will require preceptor to intervene

the student nurse shares pt information with a friend

nurse wants to reduce data entry errors on comp. system-which action should nurse take?

chart on the computer immediately after care is provided

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Documentation & informatics Ch 26 Potter/Perry

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Questions 25

Answers

1
hospital is using a computer system that allows all health care providers to use a protocol sys to document care they pr
computerized provider order entry system
clinical decision support system
nursing process design
critical pathway design
2
nurse is member of interdisciplinary team that uses critical pathways on day 2 of hospital stay the pt should be sitting
focus chart using the DAR format
add this data to problem list
document the variance in the pts record
report a positive variance in the next interdisciplinary team meeting
3
nurse wants to find the daily weights of a pt- which form will the nurse use
database
graphic record and flow sheet
progress notes
pt care summary
4
nurse is providing care to group of pts. which situation will require nurse to obtain telephone order?
at 0800 nurse and health care provider make rounds,PCP tells nurse an orde
as the nurse and health care provider leave a pts room, the PCP gives the n
nurse reads order correctly as written by health care provider in pts med r
at 0100 pts BP drops from 120/80 to 90/50 and incision dressing is sat.
5
nurse is auditing & monitoring pts health records. which action is the nurse taking?
basing reimbursement upon the diagnosis related groups documented in pts re
realizing that care no documented in the pts record still qualifies as care
comparing data in pts record to determine whether a new treatment had bette
determining the degree to which standards of care are met by reviewing pt r
6
nurse exchanges info with the oncoming nurse about pts care. which action did the nurse complete?
referral
acuity rating
electronic record entry
verbal report
7
nurse in longterm care setting that is funded by medicare/caid is completing standardized protocols for asses. and care
intake assessment form and auditing phase
a minimum data set
focused assessment of specific body system
admission assessment and acuity level
8
nurse is teaching staff about health care reimbursement. which info should nurse include in teaching lesson?
clinical info system must be installed by 2014 to obtain health care reimbu
home health, long term care, and hospital nurses documentation can affect r
HIPPA is the basis for establishing reimbursement for health care
a "near miss" helps determine reimbursement issues for health care
9
nurse needs to begin d/c planning for a pt admitted with PNA and congested cough. when is the BEST time the nurse should
after the congestion is treated
right before d/c
upon admission
when the PCP writes the order
10
preceptor is working with a new nurse on documentation. which situation will call preceptor f/u
new nurse ends each entry with signature and title
new nurse charts consecutively on every other line
new nurse documents only for self
new nurse keeps the password secure
11
nurse is completing an OASIS data set on a pt. the nurse works in which area?
Long term care facility
Skilled Nursing Facility /SNF
ICU
home health
12
nurse had taught pt how to use crutches.pt went up/down stairs using crutches with no diff. which info will
deficient knowledge related to never using crutches
demonstrated use of crutches
used crutched with no difficulty
pt went up and down stairs
13
home health nurse is preparing for an initial home visit. which info should be included in pts home care med record
step by step skills manual
reports to third party payers
nursing process form
list of possible procedures
14
nurse is charting. which info is critical for the nurse to document?
pt recorda pain medication, Lortab
family is poor and had to go on welfare
pt had a good day with no complaints
family is demanding and argumentative
15
nurse is teaching staff about informatics. which info from the staff indicates the nurse needs to f/u?
nurse needs to know how to find, eval., and use info effectively
be proficient in informatics, nurse should be able to discover, retrieve, a
if a nurse has computer competency, nurse is competent in informatics
nursing informatics is a recognized specialty area of nursing practice
16
nurse had provided care to a pt. which entry should nurse document in the pts record
pt is hard to care for and refuses all treatments and meds. family is prese
status unchanged, doing well
pt seems to be in pain and states " I feel uncomfortable"
left knee incision 1 inch in length w/o redness, drainage, edema
17
nurse is charting on pts record. which action will the nurse take that is accurate legally?
uses correction fluid to correct error
charts legibly
writes entry for another nurse
states pt is belligerent
18
after providing care a nurse charts in the pts record. what entry will the nurse document?
appears restless when sitting in the chair
apparently is asleep with eyes closed
skin pale and cool
drank adequate amounts of water
19
nurse wants to find all the pertinent pt info in one record, regardless # of times the pt entered the health care sys. w
electronic problem record
electronic medical record
electronic charting record
electronic health record
20
pt is planning to be d/c home. which info should the nurse include?
activity level
standardized care plan
community resources
signature for verbal order
21
pt with dx of PNA. which entry should nurse chart to help with financial aid?
uses incentive spirometer to encourage coughing. lung congested upon auscul
status unchanged. remains stable with no abnormal findings. checked every 2
cooperative, pt coughed and deep breathed using pillow as splint. stated "f
breathing w/o difficulty, sitting up in bed watching TV. had good day
22
a nurse preceptor working with student nurse. which behavior by student nurse will require preceptor to intervene
student nurse reviews the pts medical record
student nurse documents meds administered to the pt
the student nurse shares pt information with a friend
student nurse reads the pts plan of care
23
nurse wants to reduce data entry errors on comp. system-which action should nurse take?
print out and review computer nursing notes at home
chart on the computer immediately after care is provided
share password with only one other staff member
use same password all the time
24
nurse is preparing to doc. a pt who has CP. which info is critical for nurse to include?
shape pain of 8/10 on scale
the family is a "pain"
pupils equal and reactive to light
had poor results from pain medication
25
nurse is discussing advantages of a nursing clinical info sys. which advantage should nurse describe?
varied clinical databases
reduced errors of omission
more time to read charts
increased hospital costs

Documentation & informatics Ch 26 Potter/Perry Flashcards | StudBud