Nokea
A patient asks to see his medical record (chart). How would the nurse respond?
- A. I cant let you do that without a doctors order.
- B. Our hospital policy is that you cant do that.
- C. I will get your chart and provide you with privacy to read it.
- D. Why would you want to do that? It will only make you worry.
Correct Answer: C
Rationale: Patients have the right to access their medical records, and the nurse should facilitate this while ensuring privacy.
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Which of the following are examples of incidental disclosures of patient health information that are permitted? Select all that apply.
- A. A nurse working in a physicians office puts out a sign-in sheet for incoming patients.
- B. Two nurses are overheard talking about a patient through the door of an empty patient room.
- C. A nurse places a patient chart in a holder on the examining room door with the name facing out.
- D. A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms.
- E. A nurse calls out the name of a patient who is seated in the waiting room.
- F. A nurse leaves a reminder for an appointment on a patients answering machine along with the results of lab work.
Correct Answer: A,B,E
Rationale: Incidental disclosures like sign-in sheets, overheard conversations in clinical settings, and calling names in waiting rooms are permitted if reasonable safeguards are in place.
A student has reviewed a patients chart before beginning assigned care. Which of the following actions violates patient confidentiality?
- A. writing the patients name on the student care plan
- B. providing the instructor with plans for care
- C. discussing the medications with a unit nurse
- D. providing information to the physician about laboratory data
Correct Answer: A
Rationale: Including the patient's name on a student care plan can expose confidential information if not properly secured, violating confidentiality.
A nurse has access to computerized standardized plans of care. After printing one for a patient, what must be done next?
- A. Date it and put it in the patients record.
- B. Sign it and put it in the Kardex.
- C. Individualize it to the specific patient.
- D. Use it as printed, based on common needs.
Correct Answer: C
Rationale: Standardized care plans must be tailored to the patient's unique needs to ensure appropriate and effective care.
A nurse organizes patient data using the SOAP format. Which of the following would be recorded under S of this acronym?
- A. patient complaints of pain
- B. patient symptoms
- C. patients chief complaint
- D. patient interventions
Correct Answer: A
Rationale: The 'S' in SOAP stands for subjective data, which includes the patient's complaints, such as pain.
Which of the following abbreviations are on the Joint Commission do not use abbreviations? Select all that apply.
- A. U (unit)
- B. QD (daily)
- C. NPO (nothing per os)
- D. mL (milliliters)
- E. > (greater than)
- F. mcg (micrograms)
Correct Answer: A,B,E
Rationale: The Joint Commission prohibits abbreviations like U, QD, and > due to their potential for misinterpretation, which can lead to medication errors.