A nurse is working in an agency that uses EHR for documentation.

Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information?

(Select all that apply.).

Use a personal password to access the system and log off when finished.

Share the password with other nurses who need to access the system.

Print out a copy of the client’s record and store it in a locked cabinet.

Report any breaches or attempted breaches of security to the appropriate personnel.

Delete any information that is incorrect or outdated from the system.

Answer and Explanation

Correct Answer : A,D

The nurse should use a personal password to access the system and log off when finished, and report any breaches or attempted breaches of security to the appropriate personnel.

These actions ensure confidentiality and security of the client’s information by preventing unauthorized access and disclosing any violations.

Choice B is wrong because sharing the password with other nurses who need to access the system violates the principle of minimum necessary access, which means that only those who need the information for a specific purpose should have access to it.

Choice C is wrong because printing out a copy of the client’s record and storing it in a locked cabinet creates a risk of loss, theft, or unauthorized disclosure of the paper record. The nurse should avoid printing out electronic health records unless absolutely necessary, and should follow the proper disposal procedures if they do.

Choice E is wrong because deleting any information that is incorrect or outdated from the system may compromise the integrity and availability of the client’s information. The nurse should follow the established policies and procedures for correcting or updating electronic health records, which may include adding an addendum or annotation to the original entry, but not deleting it.

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Correct Answer is ["A","B","C"]

Explanation

Documentation should be done as soon as possible after an event has occurred, because this ensures accuracy, timeliness, and continuity of care.Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs.Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.

Choice D is wrong because documentation should not include opinions, judgments, or assumptions about the client’s condition, as these are not based on facts or evidence and may be biased or inaccurate.Documentation should be factual, accurate, and objective.

Choice E is wrong because documentation should reflect the nursing process and the standards of care, but this is not a complete statement.Documentation should also reflect the patient’s perspective, preferences, and goals.Documentation should be patient-centered, holistic, and individualized.

Normal ranges for clinical observations vary depending on the patient’s age, health status, and other factors.

However, some general ranges are:.

• Temperature: 36.5°C to 37.5°C.

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: 120/80 mmHg or lower.

• Oxygen saturation: 95% or higher.

Sources:.

A. Vital signs. B. Allergies. C. Medication administration. D. Medical history. E. Intake and output.

Correct Answer is ["A","B","C","E"]

Explanation

A flow sheet is a type of document that recordsroutineandfrequentdata in agraphicalortabularform.It is used tomonitorandevaluatethe patient’s condition and response to treatment over time.A flow sheet should include information that isrelevant,conciseandeasy to read.

• Choice A is correct because vital signs are one of the most common and important data that need to be recorded and monitored regularly for any patient.

• Choice B is correct because allergies are essential information that can affect the patient’s treatment plan and prevent adverse reactions.

• Choice C is correct because medication administration is another crucial data that shows what drugs, doses, routes and times the patient has received or will receive.

• Choice D is wrong because medical history is not a routine or frequent data that needs to be recorded in a flow sheet.Medical history is usually documented in a separate form that provides more details and background information about the patient’s past and present health conditions.

• Choice E is correct because intake and output are important data that indicate the patient’s fluid balance and renal function.

They need to be recorded and monitored regularly, especially for patients who have fluid restrictions.

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A nurse is working in an agency that uses EHR for documentation. Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information? (Select all that apply.).

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Naxlex Comprehensive Predictor Exams

Which of these statements about documentation are true? (Select all that apply.).

Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is ["A","B","C","E"]

Explanation

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A nurse is working in an agency that uses EHR for documentation.

Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information?

(Select all that apply.).