Patient health care records are:

not used by anyone else but the direct care providers

concise, legal records of all care given and responses

owned by the patient, who has a right to see the data any time he/she wishes

confidential information and cannot be taken to court

Answer and Explanation

The Correct Answer is B

A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.

B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.

C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.

D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.

Nursing Test Bank

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Free Nursing Study Resources

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

Explanation

A. Repeat the details of the prescription back to the provider: Verbal/telephone orders must be read back to ensure accuracy (known as read-back verification).

B. Record the reason for the call made to the provider and the results of the call in the Nurse’s Notes: Documentation should include:

Why the call was made
Provider’s response and order
Patient’s condition before and after intervention

C. Tell the charge nurse that the provider has prescribed morphine by telephone: While communication with the charge nurse is good practice, it does not replace proper documentation and verification.

D. Refuse to accept the verbal prescription because this is not an emergency: While verbal orders should be limited to emergencies, they can be accepted in certain non-emergency cases, provided read-back verification and documentation are done.

A. signs of fluid overload B. symptoms C. data clustering D. urinary retention

Correct Answer is C

Explanation

A. Signs of fluid overload: Fluid overload presents with edema, crackles in lungs, and increased blood pressure, not dry skin and mucous membranes.

B. Symptoms: Symptoms are subjective (e.g., pain, nausea), while the given findings are observable signs.

C. Data clustering: The nurse groups related signs (flushed skin, dry mucous membranes, elevated temperature) to identify a pattern suggesting dehydration or fever.

D. Urinary retention: Urinary retention is associated with bladder distention and reduced urine output, not dry skin and mucous membranes.

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Patient health care records are:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (Select all that apply)

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

Explanation

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:

Correct Answer is C

Explanation

JCAHO regulates standards of care to:

How is Maslow's Hierarchy of Human Needs used by nurses in a clinical setting?

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)

In which step of the nursing process do nurses look at outcomes?

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date it is determined that a/an: