NRSE 260 EXAM 4 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+||BRAND NEW
Information regarding a patient's health status may not be released to non-health care team members
because:
A. legal and ethical obligations require health care providers to keep information strictly confidential.
B. regulations require health care institutions to document evidence of physical and emotional well-
being.
C. reimbursement issues related to patient care and procedures may be of concern.
D. fragmentation of nursing and medical care procedures may be identified. - (ANSWER)A- Rationale:
Under HIPAA laws, a patient's medical information can only be released to team members, unless
express written consent is given by the patient.
A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When
completing the admission paper work, the nurse needs to record:
A. an interpretation of patient behavior.
B. objective data that are observed.
C. lengthy entry using lay terminology.
D. abbreviations familiar to the nurse. - (ANSWER)B- Rationale: Objective data are part of the
assessment portion of the nursing process. All data collected during the nursing process should be
documented.
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an
example of:
A. PIE documentation.
B. SOAP documentation.
C. narrative charting.
D. charting by exception. - (ANSWER)C- Rationale: Writing subjective data, which includes the
information the patient verbalizes, is written in narrative charting.
A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose
of an incident report is to:
A. exchange information among health care members.
, NRSE 260 EXAM 4 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+||BRAND NEW
B. provide information about patients from one unit to another unit.
C. ensure proper care for the patient.
D. aid in the hospital's quality improvement program. - (ANSWER)D- Rationale: Any deviation from the
norm, such as a patient fall, can be used to improve quality. Incidents are gathered and assessed to see
if there is a way to prevent it from happening again.
What does EHR stand for? - (ANSWER)Electronic Health Record:
- digital record of health info
- streamlined sharing of updated info
- allows patients medical info to move with them
-access to tools that providers can use for decision making
What does EMR stand for? - (ANSWER)Electric Medical Record:
- digital version of the chart
-not designated to be shared outside the individual practice
- patient record does not easily travel outside of practice
- mainly used by providers for diagnosis and treatment
What is HIPPA? - (ANSWER)the privacy rule requires that nurses protect all written and verbal
communication about patients
Information Security Protocols - (ANSWER)• Log off from the computer before leaving the workstation
to ensure that others cannot view protected health information on the monitor
• Never share a user ID or password with anyone
• Never leave a medical record or other printed or written PHI where others can access it.
ANSWERS) |ALREADY GRADED A+||BRAND NEW
Information regarding a patient's health status may not be released to non-health care team members
because:
A. legal and ethical obligations require health care providers to keep information strictly confidential.
B. regulations require health care institutions to document evidence of physical and emotional well-
being.
C. reimbursement issues related to patient care and procedures may be of concern.
D. fragmentation of nursing and medical care procedures may be identified. - (ANSWER)A- Rationale:
Under HIPAA laws, a patient's medical information can only be released to team members, unless
express written consent is given by the patient.
A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When
completing the admission paper work, the nurse needs to record:
A. an interpretation of patient behavior.
B. objective data that are observed.
C. lengthy entry using lay terminology.
D. abbreviations familiar to the nurse. - (ANSWER)B- Rationale: Objective data are part of the
assessment portion of the nursing process. All data collected during the nursing process should be
documented.
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an
example of:
A. PIE documentation.
B. SOAP documentation.
C. narrative charting.
D. charting by exception. - (ANSWER)C- Rationale: Writing subjective data, which includes the
information the patient verbalizes, is written in narrative charting.
A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose
of an incident report is to:
A. exchange information among health care members.
, NRSE 260 EXAM 4 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+||BRAND NEW
B. provide information about patients from one unit to another unit.
C. ensure proper care for the patient.
D. aid in the hospital's quality improvement program. - (ANSWER)D- Rationale: Any deviation from the
norm, such as a patient fall, can be used to improve quality. Incidents are gathered and assessed to see
if there is a way to prevent it from happening again.
What does EHR stand for? - (ANSWER)Electronic Health Record:
- digital record of health info
- streamlined sharing of updated info
- allows patients medical info to move with them
-access to tools that providers can use for decision making
What does EMR stand for? - (ANSWER)Electric Medical Record:
- digital version of the chart
-not designated to be shared outside the individual practice
- patient record does not easily travel outside of practice
- mainly used by providers for diagnosis and treatment
What is HIPPA? - (ANSWER)the privacy rule requires that nurses protect all written and verbal
communication about patients
Information Security Protocols - (ANSWER)• Log off from the computer before leaving the workstation
to ensure that others cannot view protected health information on the monitor
• Never share a user ID or password with anyone
• Never leave a medical record or other printed or written PHI where others can access it.
