Nokea
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.
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Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse?
- A. problem-oriented medical record
- B. charting by exception
- C. PIE charting system
- D. focus charting
Correct Answer: B
Rationale: Charting by exception only documents deviations from the norm, which may omit critical details, making it less defensible in court.
A nurse uses informatics to plan nursing care for a patient. Which three terms best describes this science as it is applied to nursing?
- A. data, information, knowledge
- B. process, documentation, analysis
- C. research, controls, variables
- D. hypothesis, nursing, practice
Correct Answer: A
Rationale: Nursing informatics involves transforming data into information and knowledge to support patient care.
In which of the following cases should a progress note be written? Select all that apply.
- A. for any nursepatient interaction
- B. when admitting a patient
- C. when receiving a patient postoperatively
- D. when assisting a patient with ADLs
- E. when a procedure is performed
- F. when a patient sends back an untouched dinner tray
Correct Answer: B,C,E
Rationale: Progress notes are required for significant events such as admissions, postoperative care, and procedures, as they reflect critical changes in the patient's condition or care.
Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry?
- A. Alice J, RN
- B. A. Jones, RN
- C. Alice Jones
- D. AJRN
Correct Answer: B
Rationale: The standard format for signing documentation is the nurse's initial, last name, and credentials (e.g., A. Jones, RN), ensuring clarity and professionalism.
Which of the following are examples of breaches of patient confidentiality? Select all that apply.
- A. A nurse discusses a patient with a coworker in the elevator.
- B. A nurse shares her computer password with a relative of a patient.
- C. A nurse checks the medical record of a patient to see who should be called in an emergency.
- D. A nurse updates the employer of a patient regarding the patients return to work.
- E. A nurse uses a computer to document a patients response to pain medication.
- F. A head nurse accesses the medical records of a nurse on her shift to check her condition.
Correct Answer: A,B,D,F
Rationale: Discussing patient information in public, sharing passwords, disclosing to unauthorized parties, and accessing records without a care-related purpose are breaches of confidentiality.