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

ethically can look at a friend's chart to see the diagnosis

shares information from a chart to protect a friend

knows that only the Patient's Bill of Rights advocates confidentiality

reads charts only for professional reasons

Answer and Explanation

The Correct Answer is D

A. Ethically can look at a friend's chart to see the diagnosis: Accessing a patient’s chart without a legitimate medical reason violates HIPAA and patient confidentiality laws.

B. Shares information from a chart to protect a friend: Confidentiality applies regardless of personal relationships. Unauthorized sharing of patient information is illegal and unethical.

C. Knows that only the Patient’s Bill of Rights advocates confidentiality: Multiple regulations, including HIPAA, protect patient confidentiality, not just the Patient’s Bill of Rights.

D. Reads charts only for professional reasons: Nurses can only access patient records when directly involved in care. Unnecessary access is a breach of confidentiality.

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Correct Answer is D

Explanation

A. Use a Nursing Diagnosis from a source other than NANDA-I: NANDA-I provides standardized nursing diagnoses that ensure accurate problem identification and care planning.

B. Limit the number of interventions: Interventions should be appropriate and sufficient rather than arbitrarily limited.

C. Select interventions which will be easy to implement: Interventions should be effective and individualized, not just easy.

D. Involve the patient in the process: Patient involvement ensures better adherence, understanding, and personalized care.

A. Incident reports must be recorded in the nurse's notes B. Institutions are only reimbursed for patient care that is documented C. Document only when not successful D. The patient record is a complete picture of individualized problems, treatments and responses to treatments

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

Explanation

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:

Correct Answer is D

Explanation

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

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

Explanation

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

Which of the following assists the nurse in the identification of nursing diagnoses?

JCAHO regulates standards of care to:

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)

Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?

The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:

What is the major concern when using a computer for documentation?

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: