A nurse is using an electronic health record (EHR) system to document the care provided to a client who has pneumonia.

The nurse should follow which of the following guidelines when using an EHR system ?

(Select all that apply.).

Use standardized terminology and abbreviations.

Enter data as soon as possible after providing care.

Share login information with other authorized users.

Review and verify data before saving or submitting.

Correct errors by drawing a single line through them.

Answer and Explanation

Correct Answer : A,B,D

Choice A is correct because using standardized terminology and abbreviations can improve the clarity, accuracy, and consistency of the documentation in an EHR system.

• Choice B is correct because entering data as soon as possible after providing care can ensure the timeliness, completeness, and validity of the information in an EHR system.

• Choice C is wrong because sharing login information with other authorized users can compromise the security, privacy, and integrity of the EHR system. HIPAA guidelines require that each user has a unique identifier and password to access the EHR system.

• Choice D is correct because reviewing and verifying data before saving or submitting can prevent errors, omissions, and discrepancies in the EHR system.

• Choice E is wrong because correcting errors by drawing a single line through them is a method used for paper records, not electronic records. Electronic records should have a mechanism to track changes and corrections without altering the original data.

: HIPAA Guidelines for Electronic Medical Records : Electronic Health Records - Health IT Playbook.

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Correct Answer is C

Explanation

Assess the client’s understanding and readiness for discharge.

This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.

The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.

Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.

The nurse should not threaten or coerce the client to stay in the hospital against his will.

Choice B is wrong because it is not the priority at this time.

The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.

Choice D is wrong because it is not the first action that the nurse should take.

The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.

A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels.It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.

Some of the benefits of cardiac catheterization are:.

• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.

• It can help determine the best treatment plan for the client based on his or her specific condition and needs.

• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.

• It can reduce the need for more invasive surgery or repeated hospitalizations.

A. It eliminates errors due to illegible handwriting. B. It allows access to multiple clients’ records at once. C. It reduces duplication of documentation among caregivers. D. It provides built-in safeguards to protect confidentiality.

Correct Answer is C

Explanation

It reduces duplication of documentation among caregivers.

This is an advantage of using an EHR system because it allows different healthcare providers to access and update the same record, avoiding unnecessary repetition and inconsistency.An EHR system also improves the quality and safety of care by providing clinical decision support, reducing medication errors, and facilitating communication among caregivers.

Choice A is wrong because it is not the only advantage of using an EHR system.While it is true that an EHR system eliminates errors due to illegible handwriting, it may also introduce new types of errors such as data entry mistakes, system failures, or unauthorized access.

Choice B is wrong because it is not an advantage of using an EHR system.

In fact, it may be a disadvantage because it poses a risk to the confidentiality and security of the clients’ records.An EHR system should have built-in safeguards to protect the privacy and integrity of the data, such as encryption, passwords, and audit trails.

Choice D is wrong because it is not an advantage of using an EHR system.It is a requirement of any health record system, whether electronic or paper-based, to comply with the ethical and legal standards of confidentiality.

An EHR system does not provide any additional safeguards that are not already present in a paper-based system.

Normal ranges for vital signs are as follows:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mm Hg.

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A nurse is using an electronic health record (EHR) system to document the care provided to a client who has pneumonia. The nurse should follow which of the following guidelines when using an EHR system ? (Select all that apply.).

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is using an electronic health record (EHR) system to document care for a client who has pneumonia. Which of the following is an advantage of using an EHR system?

Correct Answer is C

Explanation

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A nurse is teaching a newly hired nurse about the legal aspects of documentation. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is using an electronic health record (EHR) system to document the care provided to a client who has pneumonia.

The nurse should follow which of the following guidelines when using an EHR system ?

(Select all that apply.).