Documentation01
The Nurse contacts the HCP about a change in the patient's condition and recieves several new orders for the patient over the phone. When documenting telephone orders in the EHR, most hospitals require a nurse to do which of the following.
A. Print out a copy of all telephone orders entered into the EHR in order to keep them in personal records for legal purposes.
B. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR.
C. Record telephone orders in the EHR, but wait to implement the order(s) until they are electronically signed by the health care provider who gave them.
D. Implement telephone order(s) immediately, but insist that the health care provider come to the patient care unit to personally enter the order(s) into the EHR within the next 24 hours.
B: ALWAYS read back your telephone orders
Which of the following orders requires clarification by the nurse?
A. Change open midline abdominal incision daily using wet-to-moist normal saline and gauze.
B. Lorazepam 0.5mg PO every 4 hours PRN for anxiety
C. Morphine sulfate 1mg IVP every 2 hours PRN severe Pain
D. Insulin aspart 8 U SQ every morning before breakfast.
Clarification: Something that was written was not complete. INCOMPLETE Orders require clarification.
It's never the WRONG drug. You are looking for missing information or abbreviations that are not approved.
D: "U" is not an approved abbreviation.
The nurse is admitting a client with dehydration. Which of the following orders should the RN Question?
1. Acetaminophen 500mg PO Q 6 hours PRN Pain
2. Administer oxygen PRN to maintain saturation greater than 92%
3. D5W mL bolus IV now.
4. Measure vital signs according to unit protocol.
Question: Deadly! Harm the Patient!
3
WE NEVER BOLUS PATIENTS WITH D5W!!!!!
The nurse is working in an agency that has recently implemented an EHR. Which of the following are acceptable practice for maintaining the security and confidentiality of EHR? (SELECT ALL THAT APPLY)
A. Using a strong password and changing your password frequently according to agency policy.
B. Allowing a temporary staff member to use your computer username and password to access the electronic record
C. Ensuring that work lists (and other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed.
D. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other healthcare providers who are not involved in the patient's care.
E. Remaining logged into a computer to save time if you only need to step away to administer medication.
A, C, D
In real life we do step away, but on the NCLEX we have to ensure to maintain security and confidentiality!
The nurse is caring for a patient with high blood pressure. Which of the following orders requires clarification by the nurse?
A. Acetaminophen 500mg PO PRN Pain
B. Amlodipine 10mg PO daily
C. 0.9% NACL 75mL/hr continuous IV
D. Furosemide 10mg PO Twice Daily
A. Acetaminophen 500mg PO PRN Pain
HOW OFTEN AS NEEDED? Typically, it will be PRN every 4 hours or every 6 hours.
The nurse who works at the local hospital is transferring a patient to an acute rehab center in another town. To complete the transfer, information from the patient's EHR must be printed and faxed to the rehab center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (SELECT ALL THAT APPLY)
A. Confirm that the fax number for the acute rehab center is correct before sending the fax.
B. Use the encryption feature on the fax machine to encode the information and make it impossible for the staff at the acute rehabilitation center to read the information unless they have the encryption key.
C. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly.
D. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces.
E. After sending the fax, place the information that was printed out in a secure canister marked for shredding.
A, B, E
Maintain Security and Confidentiality
The nurse is administering a dose of metoprolol to a patient. As the bar code information on the medication is scanned, an alert appears on the computer screen. "Do not administer dose if apical heart rate (HR) is less than 60 beats/minute or systolic blood pressure (SBP) is less than 90mm Hg"
The Alert that appeared on the computer screen is an example of what type of system?
A. Clinical decision support system (CDSS)
B. Charting by exception
C. Electronic Health Record (EHR)
D. Computerized physician order entry (CPOE)
A
There are a lot of things we do in charting and we know how to do it and why, but we do not know the official name for it.
The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon by telephone to discuss concerns. Which of the following is the most appropriate way for the nurse to document this conversation?
A. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN
2, 09-3018: Notified Dr. Oakman by phone that there is a new area of redness around the patients incision. T. Wright, RN
3. 1015: Contacted Dr. Oakman and notified about changes in abdominal incision. T. Wright, RN.
4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about a new area of bright red erythema extending approximately 1 inch around the circumference of the midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN.
4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about a new area of bright red erythema extending approximately 1 inch around the circumference of the midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN.