Chapter 03: Documentation and Informatics

Chapter 03: Documentation and Informatics

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse discovers a medication error on another nurse’s documentation, so the nurse completes an incident report. Which statement should the nurse include in the report?

a.	“Nurse mistakenly gave the wrong dose of medication for pain.”
b.	“Nurse gave incorrect dose of pain medication, but patient is all right.”
c.	“Morphine 10 mg IM given rather than morphine 5 mg IM as ordered.”
d.	“Physician will be notified of error when he makes rounds tomorrow.”

 

 

ANS:  C

Stating that the patient received morphine 10 mg instead of 5 mg is a factual statement to include on an incident report because it is objective and provides no interpretation or conjecture from the nurse. The remaining choices are incorrect statements that do not accurately reflect what occurred. The physician needs to be notified as soon as the patient has been assessed, not the following day.

 

DIF:    Cognitive Level: Apply                   REF:   Page 42

OBJ:   NCLEX: Safe and Effective Care     TOP:   Nursing Process: Implementation

 

2. The nurse is documenting the care of a patient. Which entry would be characteristic of charting by exception (CBE) as a documentation method?

a.	The patient needed to be turned every hour because of increasing pain.
b.	The patient’s vital signs are stable.
c.	The patient’s gait was steady with assistance from physical therapy.
d.	There was no odor when the dressing was removed.

 

 

ANS:  A

CBE allows the nurse to specify exceptions to normal nursing assessments efficiently without documenting the normal assessment data and reducing the amount of narrative writing in patient documentation. The emphasis is on recording abnormal findings and trends in clinical care. It is a shorthand method for documenting based on defined standards for normal nursing assessments and interventions. CBE simply involves completing a flow sheet that incorporates these standards, thus minimizing the need for lengthy narrative notes. Increasing pain would not be expected and would be outside the “normal” or “expected.”

 

DIF:    Cognitive Level: Understand            REF:   Page 39 | Page 41

OBJ:   NCLEX: Safe and Effective Care     TOP:   Nursing Process: Assessment

 

3. The nurse is documenting on a patient with a respiratory problem. Which patient datum documented by the nurse is the least objective?

a.	Cool and dusky skin
b.	Low flow rate oxygen
c.	30 breaths per minute
d.	Very restless and drowsy

 

 

ANS:  B

Low flow rate oxygen is the least objective datum and the datum most subject to interpretation because the quantity of oxygen is not as precise as “liters/minute” or the “percentage” of oxygen. The remaining options provide more verifiable data.

 

DIF:    Cognitive Level: Understand            REF:   Page 40

OBJ:   NCLEX: Safe and Effective Care     TOP:   Nursing Process: Assessment

 

4. The nurse runs into a co-worker whose family friend is a patient on the unit. The co-worker asks about the friend’s health problems. Which is the correct response by the nurse?

a.	“Your friend told us to say nothing.”
b.	“Why don’t you ask your friend now?”
c.	“You know I can’t talk about the patients.”
d.	“Well, it was really a very difficult surgery.”

 

 

ANS:  C

The nurse can’t talk about the co-worker’s friend or acknowledge the friend’s presence in the facility without breaching the friend’s right to privacy, so the nurse reminds the co-worker about confidentiality.

 

DIF:    Cognitive Level: Apply                   REF:   Page 36

OBJ:   NCLEX: Safe and Effective Care     TOP:   Nursing Process: Planning

 

5. The nurse is providing home care for a patient with an infection that is not improving. The patient refuses to see an infectious disease specialist. What should the nurse include in the documentation of the patient teaching provided?

a.	The discussion about the consequences of refusing to see a specialist and the patient’s response
b.	The explanation that avoiding the specialist will most likely lead to a terrible outcome
c.	A hopeful explanation that this will most likely be the last medical specialist that the patient will need to see
d.	The recommendation that the patient should discuss the decision with the family

 

 

ANS:  A

The nurse documents the discussion about the consequences of refusing to see a specialist and the patient’s response. Documenting the factual information presented about the risks of refusing treatment and the patient’s specific response to it (continued refusal to seek a specialist) are key pieces of information to include. The nurse should neither try to scare the patient into seeing the specialist nor provide false hope that only one consultation will be required. As long as the patient is competent to make a decision, the nurse must accept his or her choice. It is a requirement to document the facts surrounding that choice.

 

DIF:    Cognitive Level: Apply                   REF:   Page 37

OBJ:   NCLEX: Safe and Effective Care     TOP:   Nursing Process: Assessment