Documentation and Informatics Practice questions

Documentation and Informatics Practice Test  

1. The nurse is caring for a postoperative patient who suddenly develops shortness of breath and a decreased oxygen saturation level. What is the nurse's priority action? 

• A. Call the healthcare provider. 

• B. Elevate the head of the bed. 

• C. Obtain vital signs. 

• D. Administer oxygen. 

2. A nurse receives a verbal order from a physician for a new medication. What action should the nurse take first? 

• A. Write the order in the patient's chart. 

• B. Repeat the order back to the physician for verification. 

• C. Immediately administer the medication. 

• D. Notify the pharmacist of the new order. 

3. Which of the following are appropriate actions to maintain patient confidentiality? (Select all that apply.) 

• A. Logging off the computer when finished documenting. 

• B. Discussing patient details only in private areas. 

• C. Sharing patient information with family members without consent. 

• D. Discarding patient notes in a secure shredder bin. 

4. A patient with diabetes is refusing to take their insulin. What is the nurse’s initial action? 

• A. Notify the healthcare provider. 

• B. Educate the patient on the consequences of missing insulin. 

• C. Document the refusal and take no further action. 

• D. Administer the insulin anyway. 

5. Which of the following documentation practices are legally appropriate? (Select all that apply.) 

• A. Charting interventions immediately after performing them. 

• B. Using standard abbreviations recognized by the facility. 

• C. Deleting an incorrect entry from the electronic health record. 

• D. Documenting only objective, factual information. 

6. A patient reports severe pain at a level of 9/10 but is refusing pain medication. What should the nurse do first?  

• A. Document the pain level and refusal. 

• B. Administer the medication as ordered. 

• C. Assess the patient's reason for refusing medication. 

• D. Notify the provider immediately. 

7. A nurse receives a telephone order from a provider. Which of the following actions are appropriate? (Select all that apply.) 

• A. Document the order with “TO” (telephone order) notation. 

• B. Read back the order to verify accuracy. 

• C. Immediately implement the order without verification. 

• D. Have the provider sign the order within the required timeframe. 

8. A nurse notices a colleague accessing patient records of a patient they are not assigned to. What is the appropriate action? 

• A. Ignore it unless the colleague does it repeatedly. 

• B. Report the incident to the supervisor. 

• C. Confront the colleague and tell them it’s inappropriate. 

• D. Ask the colleague why they are accessing the record. 

9. When documenting a change in a patient’s condition, which of the following should be included? (Select all that apply.) 

• A. The patient’s subjective complaints. 

• B. The nurse’s personal opinion on the situation. 

• C. Any interventions taken and the patient’s response. 

• D. The exact time the change was noticed. 

10. A nurse is teaching a newly hired nurse about documenting patient care. Which statement indicates a need for further teaching? 

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

• B. "I should use only facility-approved abbreviations in my notes." 

• C. "I should ensure my documentation is factual and objective." 

• D. "I should document care as soon as possible after performing it." 

11. A nurse is documenting a patient’s wound assessment. Which statement is the most appropriate? 

• A. "The wound looks better than yesterday." 

• B. "The wound is healing well." 

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

• D. "The patient’s wound appears improved." 

12. What is the nurse’s priority when receiving a hand-off report from another nurse? 

• A. Reviewing the patient’s entire medical history. 

• B. Asking about any new orders or changes in condition. 

• C. Verifying all previous nurse’s documentation. 

• D. Performing a full physical assessment before reviewing the report. 

13. A nurse receives a critical lab result over the phone. What is the nurse’s priority action? 

• A. Document the result immediately in the patient’s chart. 

• B. Notify the healthcare provider. 

• C. Recheck the lab result in an hour. 

• D. Call the patient’s family to inform them. 

14. Which of the following are examples of proper use of electronic health records? (Select all that apply.) 

• A. Using personal login credentials to access records. 

• B. Copying and pasting previous notes to save time. 

• C. Ensuring documentation is timely and accurate. 

• D. Logging out of the system when stepping away. 

15. A nurse is discussing the importance of patient portals with a patient. Which benefit should the nurse emphasize? 

• A. “It allows you to directly change your medication doses.” 

• B. “It provides access to your health records and lab results.” 

• C. “It replaces the need for face-to-face provider visits.” 

• D. “It allows you to diagnose your own conditions.” 

16. Which situation would be considered a breach of patient confidentiality? 

• A. Sharing a patient’s diagnosis with a provider involved in their care. 

• B. Discussing a patient’s condition in an elevator. 

• C. Reviewing a patient’s medical record for an assigned case. 

• D. Providing discharge instructions to the patient. 

17. A patient’s blood pressure suddenly drops to 80/50 mmHg. What should the nurse do first? 

• A. Notify the provider immediately. 

• B. Recheck the blood pressure manually. 

• C. Increase IV fluid rate as prescribed. 

• D. Place the patient in a supine position. 

18. A nurse finds an unresponsive patient with no pulse. What is the first action? 

• A. Call for help and initiate CPR. 

• B. Check the patient’s medical record for a DNR order. 

• C. Notify the healthcare provider. 

• D. Administer oxygen. 

19. A patient is prescribed a medication they have a known allergy to. What is the nurse’s priority action? 

• A. Notify the provider immediately. 

• B. Administer the medication since it is prescribed. 

• C. Document the allergy and proceed with administration. 

• D. Give the medication with an antihistamine. 

20. A nurse is preparing to discharge a patient. What should be included in discharge documentation? (Select all that apply.) 

• A. Patient’s understanding of discharge instructions. 

• B. List of medications and follow-up appointments. 

• C. Subjective nurse opinions about patient readiness. 

• D. Patient’s ability to perform self-care. 

Answer Key & Rationales

1. B. Elevate the head of the bed
Rationale: Raising the head of the bed promotes lung expansion and improves oxygenation. Oxygen can be administered after ensuring the airway is open.

2. B. Repeat the order back to the physician for verification
Rationale: Verbal orders must be confirmed through read-back to ensure accuracy before being documented or administered.

3. A, B, D
Rationale: Logging off, discussing information privately, and properly discarding notes protect confidentiality. Sharing information without consent is a HIPAA violation.

4. B. Educate the patient on the consequences of missing insulin
Rationale: Patient autonomy must be respected, but education can help them make an informed decision.

5. A, B, D
Rationale: Timely documentation, using standard abbreviations, and maintaining objectivity are correct. Deleting records is illegal; corrections should be documented appropriately.

6. C. Assess the patient’s reason for refusing medication
Rationale: Understanding the reason for refusal allows the nurse to address concerns and offer alternatives.

7. A, B, D
Rationale: Telephone orders should be documented, read back, and signed within the required timeframe. Orders should not be implemented without verification.

8. B. Report the incident to the supervisor
Rationale: Unauthorized access to patient records is a privacy violation and must be reported.

9. A, C, D
Rationale: Subjective complaints, interventions, and the exact time of change are crucial documentation elements. Opinions should not be included.

10. A. "I should document my interventions before performing them to save time."
Rationale: Documentation must reflect care that has already been provided, not anticipated care.

11. C. "The wound is 2 cm in diameter, with red granulation tissue and no drainage."
Rationale: Objective, measurable descriptions are best for documentation.

12. B. Asking about any new orders or changes in condition
Rationale: The most relevant information for safe hand-off includes new orders and patient condition changes.

13. B. Notify the healthcare provider
Rationale: Critical lab results require immediate communication to ensure appropriate intervention.

14. A, C, D
Rationale: Using personal credentials, timely documentation, and logging out protect data security. Copying and pasting notes can lead to errors.

15. B. "It provides access to your health records and lab results."
Rationale: Patient portals enhance patient engagement by providing access to health information but do not replace provider guidance.

16. B. Discussing a patient’s condition in an elevator
Rationale: Conversations in public places risk unintentional breaches of confidentiality.

17. B. Recheck the blood pressure manually
Rationale: Verifying the reading ensures accuracy before implementing interventions.

18. A. Call for help and initiate CPR
Rationale: The priority is initiating life-saving measures following the BLS (Basic Life Support) guidelines.

19. A. Notify the provider immediately
Rationale: Administering an allergenic medication can cause a severe reaction. The provider must reassess the prescription.

20. A, B, D
Rationale: Discharge documentation should include patient understanding, medications, follow-up appointments, and self-care abilities. Subjective nurse opinions are not appropriate.