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 B

Explanation

A. Evaluation, planning, assessment, implementation: Evaluation is the last step, not the first.

B. Assessment, planning, implementation, evaluation
The correct order of the nursing process is:

Assessment – Gather data
Planning – Develop goals and interventions
Implementation – Carry out the plan
Evaluation – Determine effectiveness and adjust as needed

C. Implementation, assessment, planning, evaluation: Assessment must come first before implementing any plan.

D. Planning, evaluation, assessment, implementation: Planning comes after assessment, and evaluation is last, not second.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select the proper order of the phases of the Nursing Process:

Correct Answer is 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

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

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:

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

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:

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

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?

Clarify the primary purpose of nursing orders:

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?