The electronic medical record was set up as a goal of the 2009 American Recovery and Reinvestment Act, for the purpose of providing a:

comprehensive plan to allow patient access to medical records.

comprehensive document of health care costs.

comprehensive plan of care for all patients.

Correct comprehensive record of a patient's history and care across all facilities and admissions.

Answer and Explanation

The Correct Answer is D

A. Comprehensive plan to allow patient access to medical records.

While electronic medical records (EMRs) do facilitate patient access to their medical information, the primary goal of the 2009 American Recovery and Reinvestment Act was broader. It aimed to improve healthcare quality, safety, and efficiency through the promotion of health IT, including EMRs.

B. Comprehensive document of health care costs.

Although EMRs can include billing information, the main purpose of EMRs is to record clinical data for patient care and not specifically to document healthcare costs.

C. Comprehensive plan of care for all patients.

EMRs are tools used by healthcare providers to record patient information and manage healthcare delivery. While they can support the creation and management of care plans, their primary function is to store patient data electronically rather than generating care plans.

D. Correct comprehensive record of a patient's history and care across all facilities and admissions.

This statement best reflects the primary goal of the electronic medical record implementation. EMRs are designed to provide accurate, comprehensive, and up-to-date information about a patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory test results, among other essential data. They ensure that this information is accessible to authorized healthcare providers across various facilities and admissions, improving continuity of care and patient safety.

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Correct Answer is B

Explanation

A. Patient leaving against medical advice:
When a patient decides to leave the hospital against medical advice, it's crucial to communicate this decision effectively. However, this situation does not specifically require a structured communication tool like SBAR. Rather, it necessitates clear communication to ensure the patient understands the risks and implications of leaving against medical advice.

B. Patient transfer to another facility:
During a patient transfer, especially between different healthcare facilities, it's essential to provide a comprehensive hand-off communication. SBAR is commonly used in such situations.

Situation: Describes the current situation and why the patient is being transferred.
Background: Provides relevant medical history and context.
Assessment: Presents the patient's current condition and vital signs.
Recommendation: Specifies what care and interventions the receiving facility should provide.
Using SBAR in this context ensures that all critical information is passed on accurately, minimizing the risk of errors and improving the continuity of care.

C. Visitor fall:
While a fall involving a visitor is an important incident, it doesn't typically require a structured communication tool like SBAR. Instead, it necessitates immediate response, assessment, and appropriate reporting within the hospital’s incident reporting system.

D. Needle stick injury to a nurse:
In the case of a needle stick injury, prompt reporting and proper follow-up are vital. While communication is crucial, it doesn't usually follow the structured format of SBAR. The nurse needs to report the incident to their supervisor or employee health, which would initiate appropriate protocols for testing, treatment, and documentation. Clear communication is necessary, but it doesn’t typically involve the use of the SBAR tool.

A. Bleeding from a chin laceration B. complain of severe chest pain C. has a fever of 102 degrees D. complains of a productive cough

Correct Answer is B

Explanation

A. Bleeding from a chin laceration: This is a significant concern, but it's generally not immediately life-threatening. The bleeding can be controlled, and it's not likely to lead to a rapid decline in the patient's condition.

B. Complain of severe chest pain: This is a critical symptom as it could indicate a heart attack or other serious cardiac issue. Chest pain could be a sign of a lack of blood flow to the heart, which can lead to severe complications if not addressed urgently.

C. Has a fever of 102 degrees: While a fever indicates an infection or inflammation in the body, a fever of 102 degrees Fahrenheit, by itself, is not an immediate life-threatening situation. It suggests an underlying issue that needs medical attention but might not be as urgent as severe chest pain.

D. Complains of a productive cough: While a productive cough (bringing up phlegm or mucus) could indicate a respiratory infection, it's generally not as urgent as severe chest pain. Respiratory issues can become serious, especially in vulnerable populations, but they often progress over a longer timeframe compared to the rapid onset of a heart attack, for example.

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The electronic medical record was set up as a goal of the 2009 American Recovery and Reinvestment Act, for the purpose of providing a:

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Naxlex Comprehensive Predictor Exams

Hand-off communication tools such as the SBAR are used in the following situation:

Correct Answer is B

Explanation

An emergency room nurse will give first priority to the patent with the most critical need, which is the patient who

Correct Answer is B

Explanation

Active listening includes

Which of the following are examples of nursing implementations? (Select All That Apply)

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The general rule is that the initial care plan for a patient is:

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Which statement is true regarding nursing diagnoses?

To conduct a physical examination of a patient, which examination technique is used?

Verbal communication includes