Documentation and Informatics Practice questions

What should the nurse's priority action be when a postoperative patient suddenly develops shortness of breath and a decreased oxygen saturation level?

Elevate the head of the bed.

What should a nurse do first after receiving a verbal order for a new medication from a physician?

Repeat the order back to the physician for verification.

Which actions help maintain patient confidentiality?

Logging off the computer when finished documenting, discussing patient details only in private areas, and discarding patient notes in a secure shredder bin.

When a patient with diabetes refuses to take their insulin, what should the nurse's initial action be?

Educate the patient on the consequences of missing insulin.

Which documentation practices are legally appropriate?

Charting interventions immediately after performing them, using standard abbreviations recognized by the facility, and documenting only objective, factual information.

If a patient reports severe pain at a level of 9/10 but refuses pain medication, what should the nurse do first?

Assess the patient's reason for refusing medication.

What actions should a nurse take after receiving a telephone order from a provider?

Document the order with 'TO' notation, read back the order to verify accuracy, and have the provider sign the order within the required timeframe.

What should a nurse do when they notice a colleague accessing patient records of a patient they are not assigned to?

Report the incident to the supervisor.

When documenting a change in a patient’s condition, what should be included?

The patient's subjective complaints, any interventions taken and the patient’s response, and the exact time the change was noticed.

Which statement indicates a need for further teaching about documenting patient care?

I should document my interventions before performing them to save time.

What is the most appropriate statement for a nurse documenting a patient’s wound assessment?

The wound is 2 cm in diameter, with red granulation tissue and no drainage.

When receiving a hand-off report from another nurse, what is the nurse’s priority?

Asking about any new orders or changes in condition.

Upon receiving a critical lab result over the phone, what is the nurse’s priority action?

Notify the healthcare provider.

Which are examples of proper use of electronic health records?

Ensuring documentation is timely and accurate, using personal login credentials to access records, and logging out of the system when stepping away.

What is a key benefit of patient portals that a nurse should emphasize?

It provides access to your health records and lab results.

Which situation is considered a breach of patient confidentiality?

Discussing a patient’s condition in an elevator.

When a patient’s blood pressure suddenly drops to 80/50 mmHg, what should the nurse do first?

Recheck the blood pressure manually.

What is the nurse's first action when finding an unresponsive patient with no pulse?

Call for help and initiate CPR.

If a patient is prescribed a medication they are allergic to, what should the nurse do?

Notify the provider immediately.

What should be included in discharge documentation for a patient?

Patient’s understanding of discharge instructions, list of medications and follow-up appointments, and patient’s ability to perform self-care.

What is the rationale for notifying a healthcare provider when a critical lab result occurs?

Critical lab results require immediate communication to ensure appropriate intervention.

What must be done when documenting care that has been provided?

Documentation must reflect care that has actually been given, not anticipated care.

What should a nurse remember to include when assessing a patient’s condition?

Objective, measurable descriptions are best for documentation.

What is the significance of documenting only objective, factual information?

It ensures that documentation remains accurate and legally defensible.