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

confidentiality

adequate forms for documentation

incorrect information

None of the answers are correct

Answer and Explanation

The Correct Answer is A

A. Confidentiality: The biggest concern is maintaining patient confidentiality due to risks of unauthorized access, hacking, and breaches of protected health information (PHI).

B. Adequate forms for documentation: Computerized charting typically has structured templates, ensuring that all necessary fields are included.

C. Incorrect information: While errors can occur, computerized charting often includes safeguards like drop-down menus, alerts, and validation checks to reduce mistakes.

D. None of the answers are correct: Confidentiality is a significant concern, making option A the best answer.

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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. a head-to-toe assessment B. subjective data collection C. objective data collection D. Maslow's Hierarchy of Needs E. Coughed up 5 mL yellow sputum

Correct Answer is A

Explanation

A. A head-to-toe assessment: A head-to-toe assessment is the most systematic approach to a complete physical exam, ensuring no body system is overlooked.

B. Subjective data collection: While subjective data is part of the process, it is not a structured approach to an entire physical exam.

C. Objective data collection: Objective data is collected during the exam, but the question asks about the approach to organizing the exam, not the data type.

D. Maslow’s Hierarchy of Needs: Maslow’s hierarchy helps prioritize care but is not a method for performing a physical assessment.

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

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

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:

Correct Answer is A

Explanation

Identify the two primary methods used to collect data:

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

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:

One benefit of computerized charting is that:

A focused assessment should be done by the nurse in all of the following situations EXCEPT:

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?

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

The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is: