This Document Contains Chapters 6 to 7 Chapter 6 Question 1 The nurse is reviewing a standardized care plan. This type of plan: Standard Text: Select all that apply. 1. Is defined for a specific medical condition 2. Is used for the client with comorbidities 3. May be incorporated into interdisciplinary plans 4. Is often based on expert content documents 5. May define a standard set of outcomes Answer: 1, 3, 4, 5 Rationale 1: The critical pathway is a standardized plan of care that is defined for a specific disease of medical condition Rationale 2: The standardized plan of care is cumbersome with multiple diagnoses Rationale 3: The standardized nursing plan of care outcomes may be incorporated with other care disciplines’ plans of care Rationale 4: The standardized plan of care is based on textbooks, evidence-based research or clinical guidelines from professional nursing organizations Rationale 5: The standardized plan of care may define a standard set of outcomes; any deviation from the standard outcome requires further assessment and planning Question 2 The individualized plan of care will be effective with 1. groups of clients. 2. one client. 3. most of the clients with that same diagnosis. 4. the physical therapy plan of care. Answer: 2 Rationale 1: The individualized plan of care is tailored to one client’s specific needs Rationale 2: The individualized care plan is tailored to meet the needs of a specific client with a specific medical condition Rationale 3: The individualized care plan is not applicable to most clients with the same diagnosis, although there may be some overlap Rationale 4: The individualized plan of care is specific to nursing Question 3 The nurse works in a facility that uses an interactive plan of care. Advantages of this type of plan of care include: Standard Text: Select all that apply. 1. Individualization for a client’s specific needs 2. It allows the nurse to choose nursing diagnoses, and outcomes 3. Use of branching logic 4. May be based on an individualized care plan 5. Works based on intuitive nursing knowledge Answer: 1, 2, 3 Rationale 1: The interactive plan of allows for individualized adaptation for a client’s specific conditions Rationale 2: It allows the nurse to select the nursing diagnoses, appropriate outcomes and interventions based on the specific client’s conditions Rationale 3: The interactive planning system based on the CCC System is designed to use branching logic to include evidence-based nursing guidelines Rationale 4: The interactive care plan may be based on a standardized plan of care, but are easily modified based on outcomes Rationale 5: The Interactive care plan is based on evidence-based nursing guidelines and knowledge of nursing clinical practice Question 4 Nursing EHR applications have been traditionally developed with little or no input from nursing personnel. This changed due to the following major initiatives: Standard Text: Select all that apply. 1. Use of preprinted care plans 2. Attention on CPOE 3. Quality initiatives by JCAHO 4. Quality initiatives by CMS 5. Documentation of national client safety, core quality, and outcome measures Answer: 2, 4, 5 Rationale 1: Preprinted care plans were unique to each facility but were not a driving force in changing the EHR for nursing documentation Rationale 2: National attention on the need for electronic nursing records to confirm completion and measure the outcome of the physician’s electronic orders Rationale 3: Quality iniatives by JCAHO were not a driving force for changing the EHR for nursing documentation Rationale 4: Quality initiatives by CMS require hospitals and other healthcare facilities to provide evidence of compliance to national client safety, core quality and outcome measures Rationale 5: Codified nursing language required to provide evidence of compliance to national client safety, core quality and outcome measures Question 5 The CCC system consists of two interrelated, classified terminologies, including 1. Protocols 2. Nursing Interventions and Actions 3. Standardized nursing diagnosis 4. Evidence based practice Answer: 2 Rationale 1: The CCC system is a definitive foundation for the design of codified computer application that support computer-based protocols; this is not a terminology Rationale 2: The CCC of Nursing interventions and Actions, and the CCC of Nursing Diagnoses and Outcomes are the two interrelated terminologies Rationale 3: Standardized nursing diagnoses are linked with interventions and outcome; this is not a terminology Rationale 4: The CCC System is based on an evidence-based approach to guide electronic documentation Question 6 The nurse understands that the main advantage of the CCC System is the: 1. Standardized approach to documenting client outcomes 2. Codified approach to documenting the nursing care processes in an EHR 3. The ability to modify the plan of care 4. The ability to collect the client’s health data Answer: 2 Rationale 1: The CCC System offers a standardized approach to documenting the nursing care processes and workflow in an EHR Rationale 2: The CCC System offers a codified and standardized approach to documenting the nursing care processes and workflow in an EHR Rationale 3: The CCC is not responsible for the ability to modify a plan of care; this is part of the nursing process Rationale 4: The CCC model follows the six steps of the Nursing Process Standard of Care Question 7 The nurse is using the CCC System framework for nursing documentation, which consists of: Standard Text: Select all that apply. 1. 27 Nursing Diagnoses 2. 3 Actual Outcomes 3. 198 Nursing Interventions 4. 3 Expected Outcomes 5. 14 Action Types Answer: 2, 3, 5 Rationale 1: The CCC System framework consists of 182 Nursing Diagnoses Rationale 2: The CCC System framework consists of three actual outcomes Rationale 3: The CCC System framework consists of 198 Nursing Interventions Rationale 4: The CCC System framework consists of three Actual Outcomes Rationale 5: The CCC System framework consists of four Action Types Question 8 The nurse understands the nursing process is a flow where the sixth step, evaluation leads to: 1. Planning new care outcomes 2. Determining new Nursing Diagnoses 3. The first to reassess 4. Implementation of new nursing interventions Answer: 3 Rationale 1: Planning new care outcomes occurs after reassessment and determining new diagnoses Rationale 2: New Nursing diagnoses are determined after reassessment of the client Rationale 3: Implementation of new nursing interventions occurs after reassessment ‘ Rationale 4: Implementation of new nursing interventions occurs after reassessment ‘ Question 9 The CCC Documentation Step that corresponds with the Assessment step of the nursing process is 1. Action Types 2. Actual Outcomes 3. Care Components 4. Nursing Interventions Answer: 3 Rationale 1: The CCC Documentation Step Action Types corresponds with the Implementation Step of the nursing process Rationale 2: The CCC Documentation Step Actual Outcomes corresponds with the Nursing Process step of evaluation Rationale 3: The CCC Documentation Step Care Components corresponds with the Nursing Process step of assessment Rationale 4: The CCC Documentation Step Nursing interventions corresponds with the Planning step of the nursing process Question 10 Using the CCC System, the nurse finds that which step of the nursing process drives the selection of interventions? 1. Assessment 2. Diagnosis 3. Planning 4. Outcome Identification Answer: 2 Rationale 1: The nurse uses the assessment of the client’s signs and symptoms to form the Nursing diagnosis Rationale 2: The Nursing diagnosis drives the selection of the appropriate interventions Rationale 3: The Planning step of the Nursing Process is the same as the Nursing Intervention step in the CCC System Framework Rationale 4: Outcome Identification is accomplished after the selection of Nursing Diagnoses Question 11 The initial step of the nursing process is 1. Diagnosing 2. Intervention identification 3. Identification of outcomes 4. Data collection Answer: 4 Rationale 1: Diagnosis is done after the analysis of the assessment data Rationale 2: Identification of interventions is done after the nursing diagnosis and expected outcomes are identified Rationale 3: Identification of outcomes is done after the nursing diagnosis is identifies Rationale 4: Data collection (of the client’s health data) is the initial step of the nursing process Question 12 The nurse analyzes the assessment data to determine 1. Expected outcomes 2. Prescribed interventions 3. Attainment of outcomes 4. Nursing diagnosis Answer: 4 Rationale 1: Expected outcomes are individualized to the client after nursing diagnosis is determined Rationale 2: Prescribed interventions refer to the specific actions or treatments recommended by a healthcare provider or based on nursing knowledge and standards. While analyzing assessment data might help inform the choice of these interventions, the actual decision on what interventions to prescribe usually comes from clinical guidelines, treatment protocols, or healthcare provider orders rather than the assessment data alone. Rationale 3: The plan of care is determined after the expected outcomes are identified Rationale 4: The attainment of outcomes is evaluated after the plan has been implemented Question 13 The nurse uses the plan of care to identify 1. the nursing interventions appropriate for the client. 2. the nursing diagnosis. 3. expected outcomes. 4. the client’s progress toward the attainment of outcomes. Answer: 1 Rationale 1: The plan of care is used to identify the nursing interventions appropriate for the client Rationale 2: The nursing diagnosis is identified after the nursing assessment is accomplished Rationale 3: The expected outcomes are identified after the nursing diagnosis is identified Rationale 4: The client’s progress toward the attainment of outcomes is identified during the evaluation step of the nursing process Question 14 The six steps of the nursing process provide 1. a basis for clinical decisions. 2. nursing data for analysis. 3. a list of Care Components. 4. a codified approach to documentation. Answer: 1 Rationale 1: The six steps of the nursing process provide the basis for clinical decisions and provision of competent nursing care Rationale 2: The CCC System follows the six steps of the nursing process and facilitates the creation of comparable nursing data for analysis and reporting Rationale 3: The CCC Documentation step of Care Components correlates with the assessment step of the nursing process Rationale 4: The CCC System offers a codified and standardized approach to documenting the nursing care processes and workflow in an EHR Question 15 The nurse is preparing to Review the Plan of Care in the EHR. Which of the tabs in the Student Edition Software will allow the nurse to access this data? 1. ADT 2. Forms 3. Options 4. Select Answer: 1 Rationale 1: The ADT tab will give rise to the client list, with two rows of highlighted table, including Review Plan of Care Rationale 2: The forms menu will not allow access to the Review Plan of Care Button Rationale 3: The Options menu located on the tool bar will not give access to the Plan of Care button Rationale 4: The select button is the first button to click when adding an encounter Question 16 The nurse works in a facility that is transitioning from paper care pathways to an EHR with nursing plans of care. What are the similarities between the two? Standard Text: Select all that apply. 1. Both include Outcome Goals 2. The nursing actions are individualized 3. Both include clinical orders 4. Both include nursing actions related to nursing diagnosis 5. Both can address the needs of a client with comorbid diagnoses Answer: 1, 4 Rationale 1: Both types of plans of care include outcome goals for the client Rationale 2: The Care pathway is not individualized Rationale 3: Neither includes clinical orders; the care pathway may have standardized clinical orders for the physician to enter in the CPOE Rationale 4: Both plans of care include nursing actions related to nursing diagnoses Rationale 5: The care pathway is not able to address the needs of a client with comorbidities Question 17 The nurse is using a CCC System to create an individualized plan of care. What is the benefit of using a CCC System? Standard Text: Select all that apply. 1. It follows the nursing process 2. It allows the nurse to enter electronic nursing orders 3. It follows a standard care plan 4. The nursing diagnoses relate to medical diagnosis 5. The quality of the plans may vary Answer: 1, 2, 4 Rationale 1: The CCC System follows the nursing process Rationale 2: The nurse can enter nursing orders into the CPOE application Rationale 3: The CCC System facilitates a plan of care capable of addressing the individualized need of a client Rationale 4: The CCC System offers nursing diagnoses related specifically to the medical diagnosis but follows the nursing process to lead to an individualized plan of care Rationale 5: The quality of the care plans is more consistent using the CCC System to guide the care plan process Question 18 The nurse is preparing to create an individualized nursing plan of care. Which of the following steps is the initial action after choosing the client’s name? 1. Locate and click the button labeled ADT 2. Locate and click the button labeled Initial Data Entry 3. Locate and click the button labeled Review Plan of Care 4. Locate and click the tab labeled Encounter Answer: 2 Rationale 1: The button labeled ADT is used to locate the client’s name Rationale 2: The button that will open the window to the nursing plan of care Rationale 3: The Review Plan of Care is for the client who already has a nursing plan of care Rationale 4: The tab labeled Encounter is not the tab that is used next Question 19 When creating an individualized plan, the nurse first reviews: 1. The Outline view of the admission note 2. Computer generated suggestions of nursing diagnoses 3. The computer generated interventions 4. The computer generated evaluation Answer: 2 Rationale 1: The nurse does not review the outline view of the admission note Rationale 2: The nurse reviews the computer generated potential nursing diagnoses that relate to the admission diagnosis Rationale 3: The nurse reviews interventions after determining the nursing diagnosis Rationale 4: The nurse does not review the evaluation when initiating a care plan Question 20 As the nurse reviews her assessment of a client, her actions in the EHR include: Standard Text: Select all that apply. 1. Click on the Px tab 2. Click on the Hx tab 3. Locate and click on the small minus sign next to a finding 4. Locate and click on the small plus sign next to the finding 5. Review entry Answer: 1, 4, 5 Rationale 1: The Px is the correct tab to open the pane in which to record the physical exam results Rationale 2: The Hx tab is the correct tab to enter client reported findings Rationale 3: A small minus sign will not open further information to be documented Rationale 4: A small plus sign will open further choices to refine the entry Rationale 5: Reviewing the entry prior to moving to nursing diagnosis is an appropriate nursing action, in order to make sure the entry is accurate Question 21 The nurse is determining nursing diagnoses for a client with bacterial pneumonia. The appropriate tab for the nurse to select is 1. Sx 2. Px 3. Tx 4. Nurse Answer: 4 Rationale 1: The Sx tab is for the subjective information reported by the client Rationale 2: The Px tab is for results of the physical examination Rationale 3: The Tx tab is for test results Rationale 4: Clicking on the Nurse tab in the upper left corner will open the Nursing Diagnoses most commonly associated with bacterial pneumonia Question 22 When using the CCC System in the interactive nursing plan of care, the initial step (s) include (s) which of the following actions: Standard Text: Select all that apply. 1. Click on the ADT tab 2. Click on the client’s name 3. Click the Review Plan of Care 4. Click Select on Menu bar 5. Click on New Encounter Answer: 1, 2, 3 Rationale 1: The ADT tab will open the client list Rationale 2: The client’s name will be in a list Rationale 3: Clicking ROC will open the client’s change to the Nursing Tab automatically Rationale 4: Select is in the second step Rationale 5: New encounter will be selected in step 2 Question 23 Prior to entering data, the nurse is careful to: Standard Text: Select all that apply. 1. enter vital signs. 2. select the date. 3. review the client’s clinical orders. 4. review the client’s nursing plan of care. 5. enter test results. Answer: 2, 3, 5 Rationale 1: Entering vital signs is entering data Rationale 2: Selecting the correct date, time and reason for encounter is done prior to entering data Rationale 3: Reviewing the client’s clinical orders is done prior to beginning a nursing entry Rationale 4: Reviewing the client’s nursing plan of care is done prior to beginning a nursing entry Rationale 5: Entering test results is data entry, and is not done at this time Question 24 The nurse enters vital signs by clicking on the 1. Sx tab 2. Hx tab 3. Px tab 4. Rx tab Answer: 3 Rationale 1: The subjective information from the client is entered using the Sx tab Rationale 2: The client’s history is entered using the Hx tab Rationale 3: The client’s vital signs are entered by using the Px tab, then Standard Measurements Rationale 4: The client’s treatments and medications are entered using the Rx tab Question 25 When documenting nursing actions, such as the interventions for Activity care, the nurse would click the mouse on: Standard Text: Select all that apply. 1. assess activity level. 2. findings. 3. report complications of activity. 4. resolve this diagnosis. 5. wet nursing diagnosis to inactive. Answer: 1, 3 Rationale 1: Clicking on activity care will open the nursing actions to be reported on as performed Rationale 2: Clicking on findings is appropriate for documenting a physical exam Rationale 3: Report Complications of Activity will open nursing actions to be reported on as performed Rationale 4: Resolve this diagnosis is not appropriate in the intervention stage of documentation Rationale 5: Setting a nursing diagnosis to inactive is done after evaluation of outcomes Question 26 To document the resolution of a nursing diagnosis, the nurse will: 1. type no longer required in the finding note. 2. type care no longer required. 3. right click on the nursing diagnosis. 4. inactivate the nursing diagnosis. Answer: 3 Rationale 1: Typing no longer required in the finding note is typed in the intervention area of the plan Rationale 2: “Care no longer required” does not document resolution of a nursing diagnosis Rationale 3: Right clicking on the appropriate nursing diagnosis will open a drop down window with “Resolve this Diagnosis” Rationale 4: It is not necessary to inactivate the nursing diagnosis Question 27 The nurse reviews the plan of care and notes that 1. CCC outcomes parallel inactive nursing diagnoses. 2. CCC outcomes parallel CCC goals, in the past tense. 3. Nursing diagnoses mirror interventions. 4. Nursing interventions mirror outcomes. Answer: 2 Rationale 1: CCC outcomes do not parallel inactive nursing diagnoses Rationale 2: CCC outcomes parallel CCC goals, in the past tense Rationale 3: Nursing diagnoses do not mirror nursing interventions Rationale 4: Nursing diagnoses do not mirror outcomes Question 28 The nurse reviews the plan of care and wishes to increase the frequency of a nursing intervention. The appropriate steps include: Standard Text: Select all that apply. 1. Right clicking on the intervention 2. Click on Assess Actions 3. Click on Teach Actions 4. Click on Manage Actions 5. Click on Change Sig Answer: 1, 5 Rationale 1: Right clicking on the intervention will open a drop down menu Rationale 2: Assess Actions is not the appropriate selection Rationale 3: Teach Actions is not the appropriate selection Rationale 4: Manage Actions is not the appropriate selection Rationale 5: Change Sig will allow the nurse to change the interval for the nursing intervention Question 29 The nurse determines the need to modify a plan of care that was initiated by a previous nurse. The appropriate action includes 1. Clicking on ADT 2. Click on Expected Outcome 3. Click on Add a Goal for this Diagnosis 4. Right click on Current and Active Diagnoses Answer: 4 Rationale 1: ADT will open the client list Rationale 2: Expected outcomes are added after diagnoses Rationale 3: Goals are added after diagnoses Rationale 4: Right clicking on Current and Active Diagnoses will allow a drop down menu to appear with a selection of “Add Nursing New Diagnosis” Question 30 After the nurse adds a new Nursing Diagnosis to the plan of care, the next step is to 1. Identify an Expected Outcome 2. Identify an Intervention 3. Identify a nursing action 4. Identify the Goal Answer: 1 Rationale 1: The nurse will identify an expected outcome for the nursing diagnosis Rationale 2: The intervention is identified after the outcome is identified Rationale 3: The nursing actions are identified after outcomes and goals Rationale 4: The goal for the diagnosis is identified after the interventions and expected outcomes Chapter 7 Question 1 The nurse explains that the abbreviation CPOE stands for: 1. Computerized patient order exchange 2. Computerized patient outcome evidence 3. Computerized provider order entry 4. Computerized prescription order entry Answer: 3 Rationale 1: The abbreviation CPOE stands for Computerized provider order entry Rationale 2: The abbreviation CPOE stands for Computerized provider order entry Rationale 3: The abbreviation CPOE stands for Computerized provider order entry Rationale 4: The abbreviation CPOE stands for Computerized provider order entry Question 2 CPOE systems will help do all of the following to improve workflow processes except: 1. Prevent lost orders 2. Identify duplicate orders 3. Improve provider productivity 4. Eliminate medication shortages Answer: 4 Rationale 1: Being able to enter orders in the computer prevents the loss of paper orders Rationale 2: The CPOE system is able to identify duplicate orders Rationale 3: The CPOE reduces the time necessary to fill orders Rationale 4: Medication shortages are independent of the CPOE system Question 3 A CPOE system would typically not be used by which of the following healthcare professionals? 1. Physician 2. Register dietician 3. Medical coder 4. Respiratory therapist Answer: 3 Rationale 1: The physician will use the CPOE system for all types of orders Rationale 2: The registered dietician will use the CPOE system for orders relating to the client’s nutritional needs Rationale 3: The medical coder does not use the CPOE system Rationale 4: The respiratory therapist may use the CPOE system to review orders related to the client’s respiratory needs Question 4 No U.S. state currently allows which of the following healthcare professionals to write prescriptions for clients? 1. Physician assistant 2. Medical assistant 3. Obstetrician 4. Nurse practitioner Answer: 2 Rationale 1: Physician assistants are licensed to write prescriptions in nearly all states Rationale 2: Medical assistants are unlicensed assistive personnel and unable to write prescriptions Rationale 3: The obstetrician is a physician, and licensed to write prescriptions Rationale 4: Nurse practitioners are licensed to write prescriptions in nearly every state Question 5 Which of the following is not an example of a laboratory service? 1. Cytology 2. Chemistry 3. Radiology 4. Blood bank Answer: 3 Rationale 1: Cytology services relate to the analysis of the structure of cells Rationale 2: Chemistry services relate to the analysis of components of the fluid sample Rationale 3: Radiology services relate to x-ray and sonography examination Rationale 4: Blood bank services relate to providing blood components to clients Question 6 The subcategory of clinical pathology would include which of the following? 1. Autopsy 2. Urinalysis 3. Biopsy 4. Genetic testing Answer: 2 Rationale 1: Anatomic pathology is the subcategory of pathology that includes pathology Rationale 2: Clinical pathology is the subcategory of pathology that includes chemistry to analyze blood, urine and other body fluids Rationale 3: A biopsy examination would fall under the subcategory of surgical pathology Rationale 4: Genetic testing would fall under the subcategory of anatomic pathology Question 7 Moira Gleason needs to have a CBC as part of her annual physical; this means Moira will most likely: 1. have her blood drawn in the emergency department of her local hospital. 2. have her blood drawn by a handheld device that then transfers test results to an EHR system. 3. need to schedule another appointment at her provider’s office to have blood work done. 4. have her blood drawn by a nurse or phlebotomist. Answer: 4 Rationale 1: Routine, non-emergent laboratory studies are not done in the emergency department Rationale 2: A CBC requires a larger sample than can be collected by a hand held device Rationale 3: Most providers have the ability to collect samples at the same time as the office visit Rationale 4: A phlebotomist or a nurse usually collects Blood samples Question 8 Which of the following statements is not true about laboratory tests? 1. In some cases a client will obtain his own specimen and bring it to a medical facility himself. 2. Providers often need the results of a laboratory test before they can develop a treatment plan for a client. 3. A CPOE system is only able to track lab orders once the client has had the test performed. 4. Values within lab test report results are compared against normal reference ranges to show if a client is outside that range. Answer: 3 Rationale 1: Clients can collect specimens such as urine themselves and bring it to the facility Rationale 2: Test results are often key to developing the plan of care; for example a client’s blood glucose result will determine the insulin dose Rationale 3: The CPOE system is able to track orders from the time they are entered Rationale 4: Lab reports include a reference, or normal, range with which to compare the client’s results Question 9 Which of the following would not be considered a benefit of electronic lab orders? 1. The provider may create a graph of test results over time. 2. The client usually learns about her test results within 36 hours or less. 3. Test results are stored in the EHR system. 4. The provider may order an unlimited number of tests for a client. Answer: 4 Rationale 1: The EHR system is able to provide a graph of test results over time, so that providers may evaluate trends and responses of the client Rationale 2: The EHR system allows the client to learn about test results within 36 hours, rather than waiting for paper reports Rationale 3: Test results are stored in the EHR system, allowing all members of the healthcare team to access the results Rationale 4: The provider is able to order tests as needed Question 10 A nurse practitioner determines that her client needs blood work done. Which of the following is not a “task” within a CPOE system? 1. Completing the requisition and obtaining a specimen 2. Obtaining a specimen and sending it to a lab 3. Ordering a lab test at the point-of-care 4. Picking up the sample and transporting it to a lab Answer: 4 Rationale 1: The lab order initiates a task for a nurse or phlebotomist to act on Rationale 2: The CPOE generates labels for the specimen and transmits thee information to the lab and the EHR Rationale 3: The provider enters the order in the CPOE system of the EHR Rationale 4: The actual transport of the specimen to the lab is done outside the CPOE Question 11 The Search feature in the Student Edition software: 1. finds every example of a word that is being searched. 2. searches for words within a current tab only. 3. requires the user to activate “automatic word completion” for that feature to work. 4. finds and shows the highest-level match for the word that is being searched. Answer: 4 Rationale 1: Search is not designed to find every instance that contains the word being searched for Rationale 2: Search identifies related findings available in other tabs Rationale 3: Search automatically performs word completion Rationale 4: Search uses the Medcin hierarchy (the tree view) and finds and shows the highest level match, and does not list all the expanded findings below it Question 12 Where will you find the Search feature in the Student Edition software? 1. The Medcin Nomenclature Pane 2. The Toolbar 3. The Entry Details field 4. The Menu Bar Answer: 2 Rationale 1: Search is not located in the Medcin Nomenclature Pane Rationale 2: Search is located on the toolbar, and uses a pair of binoculars as an icon Rationale 3: Search is not located in the Entry Details field Rationale 4: Search is not located in a menu Question 13 The best way to ensure that you will find a word quickly using the Search feature is to: 1. spell the word correctly. 2. search from within the correct tab. 3. use plurals when needed. 4. set the List Size to 1. Answer: 1 Rationale 1: Spelling the word correctly will allow Search to work quickly Rationale 2: Search will identify findings from all tabs Rationale 3: Search does not need plurals; this function uses a word completion feature Rationale 4: Search does not require a list setting Question 14 The nurse practitioner orders a lipids panel test using the Entry Details Prefix field. This means 1. that particular test has been performed by the clinic. 2. the medical assistant has completed the lab requisition form. 3. the lipids panel test is added to the Plan section of the encounter note. 4. the lipids panel test becomes part of the Physical findings. Answer: 3 Rationale 1: The prefix field choice would be ordered, and means it was not yet performed Rationale 2: The prefix field choice does not indicate that the MA has completed a form Rationale 3: The prefix field choice for this test will be noted in the Plan section of the encounter note, as part of the client’s plan of care Rationale 4: The lipids panel test has not yet be performed, so is not part of the physical findings Question 15 John Brown arrives at a rheumatology clinic with a diagnosis of “possible rheumatoid arthritis.” What does this mean? 1. Mr. Brown has been referred to a rheumatologist for an appointment. 2. Mr. Brown’s physician needs more information before confirming the diagnosis. 3. Mr. Brown has most of the symptoms of this condition, but not all of them. 4. Mr. Brown’s insurance plan will not pay for this visit. Answer: 2 Rationale 1: The referral is independent from the diagnosis Rationale 2: The diagnosis of “possible” indicates that the client’s diagnosis has not been confirmed Rationale 3: The diagnosis stated indicates that there may be symptomology, but confirmation has not been made Rationale 4: The diagnosis is unrelated to the insurance plan reimbursement Question 16 A hospital inpatient needs an x-ray of her lung. The nurse understands that this order will originate from: 1. CPOE 2. PACS 3. RIS 4. CDR Answer: 1 Rationale 1: The CPOE will originate the order Rationale 2: PACS stands for picture archiving and communicating system, and is used for storing diagnostic images Rationale 3: RIS stands for radiology information system, which interfaces with the EHR CPOE system for radiology orders Question 17 Which of the following types of diagnostic images uses the injection of a radioactive substance called a tracer as part of the imaging process? 1. x-ray 2. CAT 3. MRI 4. PET Answer: 4 Rationale 1: An x-ray image does not use any type of contrast media or tracer Rationale 2: Computerized axial tomography uses x-rays to see into the body, and is done with or without contrast media Rationale 3: Magnetic resonance imaging uses magnetic fields and pulses of energy to create images; it may be done with or without contrast media Rationale 4: Positron emission tomography combines CT and nuclear scanning, and uses a tracer which is injected into a vein Question 18 Why are radiology reports rarely available as a codified EHR record? 1. Because this specialty has been slower than other specialties to implement EHR systems 2. Because radiology reports are transmitted via DICOM 3. Because most radiology reports are still dictated 4. Because as part of the HIPAA Privacy Rule, radiology offices are not permitted to send electronic files to other providers Answer: 3 Rationale 1: Radiology reports are usually originated in electronic text format Rationale 2: Digital Imaging and Communications in Medicine (DICOM) is the standard for electronic transmission of images Rationale 3: Most radiology reports are dictated and transcribed by a medical transcriber Rationale 4: DICOM and HL7 allow for communication of data from provider to provider, and EHR systems adhere to HIPAA standards Question 19 A component of a pharmacy computer system that checks for potential medication dosing errors is known as: 1. DAW 2. DICOM 3. Dx 4. DUR Answer: 4 Rationale 1: DAW indicates that a medication is to be dispensed as written Rationale 2: DICOM or Digital Imaging and Communications in Medicine, is the standard for electronic transmission of images Rationale 3: Dx indicates diagnosis Rationale 4: DUR, or drug utilization review, reduces the client’s risk of adverse drug reactions Question 20 The nurse understands that the EHR system in the hospital protects the client by closing the loop on medication administration. Which of the following statements about a hospital’s closed loop of medication administration is correct? 1. It may be applied to both a paper-based and CPOE system. 2. It is completely automated. 3. It helps support the “10 Rights” of medication administration. 4. Its use requires the client’s prior consent. Answer: 3 Rationale 1: Closing the loop starts with electronic medication prescription from CPOE Rationale 2: Medication administration is not completely automated. Rationale 3: Closing the loop supports the “10 Rights” of medication administration by requiring electronic verification of medication, client, documentation, dose, time, route as well as documenting response to medication, or refusal of medication by the client Rationale 4: The client does not make medication administration policy in the facility; the client does have the right to refuse medication Question 21 The nurse understands that there are ‘10 rights’ for safe medication administration. These rights include: Standard Text: Select all that apply. 1. The right route of administration 2. The right to omit a medication 3. The right assessment 4. The right nurse 5. The right client education Answer: 1, 3, 5 Rationale 1: Safe administration of medication includes verifying the route of administration of the medication Rationale 2: The nurse does not have the right to make a decision to omit a medication unilaterally; the order may be reviewed with the prescriber to ensure safety Rationale 3: Some medications require assessment of vital signs or other parameters prior to administration; examples would include digoxin (apical heart rate measurement) and insulin coverage (blood glucose measurement) Rationale 4: The right nurse is not one of the “10 Rights”; the right client is one of the checks the nurse must do Rationale 5: The nurse needs to give the client all the necessary information about a medication, and how it will yield the best result; for example completing a course of antibiotics Question 22 The physician has given the nurse a telephone order for pain medication for a client in the hospital. The nurse performs the following actions in the EHR: Standard Text: Select all that apply. 1. Clicks on Encounter to review the plan of care 2. Document nursing assessment of pain level 3. Search for medication ordered in the Dx tab 4. Clicks on Plan of care to review clinical orders 5. Review prescription information for accuracy Answer: 2, 4, 5 Rationale 1: The nurse clicks on ADT to select client and then access Review Plan of Care Rationale 2: The nurse documents pain assessment using the Px tab, and the Vital Signs tree Rationale 3: The nurse searches for the ordered medication in the Rx tab Rationale 4: The nurse clicks on Plan of Care to review clinical orders to make sure there is no stronger medication already ordered Rationale 5: The nurse reviews the prescription information prior to clicking on Save Rx Question 23 The nurse enters a medication that was verbally ordered by the provider. After clicking Save Rx, the nurse realizes that the order was entered incorrectly. The correct action is to 1. delete the order. 2. use the Rx Inquiry function. 3. re-enter the order. 4. ask the provider to change the order. Answer: 2 Rationale 1: The order may be changed or discontinued, but not deleted Rationale 2: The Rx Inquiry function in the prescription window will allow the nurse to change the entry Rationale 3: The order should only be re-entered if the previous order is discontinued Rationale 4: The nurse can correct the entry error Question 24 ICD-9-CM and ICD-10 codes are used for: Standard Text: Select all that apply. 1. Statistical studies of causes of death 2. Billing specific client services 3. Standardized coding of diseases 4. Statistical studies of injury 5. Creating problem lists and treatment plans Answer: 1, 3, 4, 5 Rationale 1: ICD-9-CM codes can be used to track causes of death, as they are used in documentation on death certificates Rationale 2: CPT codes are used for billing specific client services; ICD codes are used to support the documentation Rationale 3: ICD codes provide a codified standard for disease documentation Rationale 4: The E codes in the ICD coding system classifies causes of injury or poisoning Rationale 5: ICD codes can be used to create specific protocols in an EHR that are based on current standards of practice Question 25 The provider is caring for a client who complains of chest pain intermittently. In the Encounter view, the provider would click which button to access a list of orders by diagnosis? 1. Search 2. List size 3. List 4. Chief Answer: 3 Rationale 1: Search provides a quick way to locate a finding in the nomenclature, but will not access the required list Rationale 2: List size is not the correct button to access this list Rationale 3: List is the correct button; it will display a drop-down list of lists to select from Rationale 4: Chief is the button used to enter chief complaint Question 26 After the nurse practitioner selects a list of Orders by Dx, which tab should automatically be displayed? 1. Dx 2. Sx 3. Px 4. Tx Answer: 1 Rationale 1: Dx should automatically be displayed Rationale 2: Sx should be selected by the provider as the second step to document the client’s current symptoms Rationale 3: Px is selected after the client’s history is taken as the provider examinees the client Rationale 4: Tx is selected to choose tests to be ordered Question 27 The nurse uses a diagnosis protocol to: Standard Text: Select all that apply. 1. document the exam and write orders quickly. 2. generate specific sets of tests that are used to monitor a particular disease. 3. generate a list of nursing interventions appropriate for a nursing diagnosis. 4. search for medications. 5. enter multiple tests. Answer: 1, 2 Rationale 1: The diagnosis related protocol assists the clinician to write orders and document the exam quickly Rationale 2: The diagnosis protocol can be used to generate a list of tests commonly ordered for the particular condition Rationale 3: A list of nursing interventions is already generated with specific diagnoses Rationale 4: Entering multiple tests is possible in the protocol, but is also possible elsewhere in the system; the diagnosis related protocol would be specific only to the one diagnosis Question 28 A quick-pick list is used by health care professionals to: Standard Text: Select all that apply. 1. display a diagnosis based order set. 2. display a list of frequently seen clients. 3. display a list of frequently ordered medications. 4. display a list of frequently ordered tests. 5. display a list of frequently seen vital signs. Answer: 1, 3, 4 Rationale 1: The quick pick list may be developed based on the orders written for a client with a specific diagnosis Rationale 2: The quick pick list is not used for clients Rationale 3: The quick pick list may be generated to display a list of medications the clinician orders frequently Rationale 4: The quick pick list may be generated to display a list of frequently ordered tests Rationale 5: The quick pick list function would not be used to display for frequently seen vital signs Question 29 A quick-pick list to order medications is accessed by the nurse by: Standard Text: Select all that apply. 1. clicking on the Tx tab. 2. clicking on the Rx tab. 3. clicking on the List button. 4. completing the Entry details portion of the screen. 5. completing the Rx Writer. Answer: 2, 3, 4 Rationale 1: The nurse will not click on the Tx tab to generate medication prescriptions Rationale 2: The nurse will click on the Rx tab and the Rx button to generate prescriptions Rationale 3: The List button will generate a list of lists to select from; the nurse will select the list and then click Load List Rationale 4: The Entry Details portion of the screen is not used at this time Rationale 5: The nurse will complete the details of the prescription in the Rx Writer Test Bank for Electronic Health Records and Nursing Richard Gartee, Sharyl Beal 9780131383722, 9780132885522
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