Nokea
Which of the following information would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply.
- A. patient sex
- B. patient admission date
- C. patient physical assessment
- D. patient insurance
- E. patient history
- F. patient ethnicity
Correct Answer: A,B,D,F
Rationale: The minimum data set includes demographic and administrative data like sex, admission date, insurance, and ethnicity to ensure standardized reporting.
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What is the primary purpose of focus charting?
- A. nursing diagnoses
- B. medical problems
- C. patient concerns
- D. expected outcomes
Correct Answer: C
Rationale: Focus charting centers on patient concerns, allowing nurses to document issues and responses systematically.
What is the primary purpose of an incident report?
- A. means of identifying risks
- B. basis for staff evaluation
- C. basis for disciplinary action
- D. format for audiotaped report
Correct Answer: A
Rationale: Incident reports are used to identify risks and improve safety by analyzing events, not for evaluation or discipline.
A physicians order reads up ad lib. What does this mean in terms of patient activity?
- A. may walk twice a day
- B. may be up as desired
- C. may only go to the bathroom
- D. must remain on bed rest
Correct Answer: B
Rationale: Up ad lib' means the patient may be up and active as desired, without restrictions.
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.
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.