N323 Week 3 Exam 1 Practice Questions and Correct Answers
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Course
NUR 323
Institution
NUR 323
What are the two most common types of information systems used by nurses? 1. Management info systems 2. Hospital info systems
List 6 examples of the use of bedside data entry 1. medication administration 2. progress notes 3. assessment data 4. careplan updates 5. activity 6. changes
Describe the ...
N323 Week 3 Exam 1 Practice Questions
and Correct Answers
What are the two most common types of information systems used by nurses? ✅1.
Management info systems
2. Hospital info systems
List 6 examples of the use of bedside data entry ✅1. medication administration
2. progress notes
3. assessment data
4. careplan updates
5. activity
6. changes
Describe the components of each format and the significance to you nursing practice
and documentation ✅1. change of shift report- pertinent info, SBAR format, giving
them responsibility
2. Telephone or verbal prescription- (avoid these)
3. Transfer report- everything about the pt, SBAR format, vitals, impairments
4. Incident report- facilities quality improvement plan
What are the 8 components of the privacy rule? ✅1. only health care members directly
responsible for pt care can access clients record
2. clients have the right to read and own a copy of medical record
3. nurses cannot photocopy any part of med rec, except for authorized exchange
between facilities
4. staff must keep medical records in a secure place, cannot use public display boards
5. electronic records are password protected, staff must only use their own password
6. Nurses must not disclose client info to unauthorized individuals
7. communication about a client must only take place in a private setting where
unauthorized individuals cannot over hear
8. To adhere to HIPPA, each facility has specific policies and procedures to monitor
staff adherence, technical protocols, computer privacy and data safety
what are the components of SOAP, PIE, DAR in each type of charting format ✅SOAP-
subjective data, objective data, assessment, plan
PIE- Problem, intervention, evaluation
DAR- Data, action, response
Which of the following information should the nurse include in a change-of-shift report?
A. Input and output for the shift
B. Blood pressure from the previous day
C. Bone scan scheduled for today
D. Medication routine from medication administration record (MAR) ✅C
, What role does HIPPA play in client confidentiality?
A. It provides a database for insurance agencies to utilize
B. Provides for data standardization
C. Provides for data classification
D. Provides for privacy and confidentiality for clients in healthcare ✅D
A nurse is discussing occurrences that require completion of an incident report with a
newly licensed nurse. Which of the following should the nurse include in the teaching?
(select all that apply)
A. Medication error
B. Needle stick
C. Conflict with provider and nursing staff
D. Omission of prescription
E. Missed lab specimen collection of a prescribed lab test ✅A,B,D
How is computer assisted instruction used in nursing?
A. It makes it easier to adjust to the use of software programs
B. It allows nurses to share health care info with clients
C. It is used to test nursing students for the NCLEX
D. It is used as a bookkeeping system ✅A
Which of the following nurse actions are appropriate when receiving a providers
prescription be telephone? (select all that apply)
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain providers signature within 24 hours
D. Decline verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone
✅A,B,C
The clients record is protected legally as a private record of the clients care. Access to
the clients record is limited to... ✅Health care professionals delivering care and the
client
Describe general guidelines for recording ✅date, time, legibility, black ink, acceptable
terminology, correct spelling
What are the 5 requirements established by J CO regarding client record documentation
✅1. timely
2. accurate
3. confidential
4. complete
5. client specific
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