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 D

Explanation

A. Oxygen will be continued: Continuing oxygen therapy is an intervention, not a measurable outcome.

B. The patient's coughing frequency will increase: While coughing can help clear secretions, increased coughing does not necessarily indicate improved airway clearance.

C. Cyanosis may be present: Cyanosis is a sign of worsening oxygenation, not an improved outcome.

D. Within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea: A desired outcome should be specific, measurable, and indicate improvement. The resolution of dyspnea demonstrates effective airway clearance.

A. block B. by exception C. focused D. SOAP

Correct Answer is B

Explanation

A. Block: Block charting documents everything over a set period (e.g., entire shift), rather than only changes.

B. By exception: Charting by exception (CBE) means only documenting significant changes in condition or treatment rather than routine care.

C. Focused: Focused charting documents care related to a specific problem, not just exceptions.

D. SOAP: SOAP (Subject

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

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?

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

Which of the following statements is correct about abbreviations?

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

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:

Select the type of assessment which is performed continuously throughout nurse-patient contact:

When discovering subjective data, recognize that they relate to:

On what form/forms should the nurse chart when administering a narcotic?