NUR 211 Exam 2
- The hospital has just implemented the use of electronic health records (EHRs). While
learning how to use this new system, the nurse realizes that EHRs may do which of the
following?
a. Limit access to the patient record to one person at a time
b. Improve access to client information at the point of care
c. Negate the use of nursing documentation
d. increase the potential for medication errors
Rationale:
Use of EHRs can improve access to patients’ information. An unlimited number of
people at a time can access a patient’s medical record. Nursing documentation is an
essential part of nursing care, whether it is completed on paper or electronically. The
potential for medication errors decreases when electronic medication administration
records are used. - Which statement best contributes to the nurse’s documentation of assessment of
patient status in the patient’s medical chart?
a. “patient had a good day with minimal complaints. Pt was pleasant and cooperative
during morning care.”
b. “Pt complained that the nurse didn’t come quickly enough when she pressed the call
button.”
c. “Pt complained of pain 7 of 10 at 7:45 am. Received pain med at 8am, reporting pain
3 of 10 at 8:30am”
d. “Pt was grumpy today, even after administration of pain medication, a back massage,
and a nap”
Rationale;
This entry is concise, complete, and objective. It gives exact times, pain levels, and
nursing interventions performed. Using terms like good or grumpy are subjective
judgments or opinions and should be avoided. Stating a patient complaint would be
okay if it listed specific times of occurrence, nursing assessment performed, and the
nursing interventions performed to correct the issue. - A patient requests a copy of his medical record. What is the correct response by the
nurse?
a. Inform him that his record is the property of the facility and cannot be accessed by
anyone but staff.
b. Tell him that the Code for Nurses does not allow you to give him access to his
records.
c. Acknowledge that he has the right to have a copy of his records, and make
arrangements per facility policy.
d. Refer his request to the hospital administrator since all such requests need to go
through proper channels
Rationale:
As part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and
updated in 2009 in The American Recovery and Reinvestment Act (ARRA), patients’
rights include obtaining, viewing, or updating a copy of their own medical records.
Usually an EHR copy is sent to the patient within 30 days. Facilities can charge the
patient for the cost incurred in copying and sending medical records. Methods for
implementation vary by facility and type of medical record. The Code for Nurses does
not control who has access to medical records. Requests would go through the medical
records department, or whoever is responsible for obtaining and copying patient
records. - A patient’s sister comes to visit and asks to read the patient’s chart. What is the best
response by the nurse?
a. Settle her in a chair at the nurses’ station and give her the chart.
b. Respond that the contents of a patient’s chart are private and confidential.
c. Tell her she can read the chart only if the patient sits with her.
d. Distract the sister by changing the subject and then walking away.
Rationale:
Without special permission from the patient, only those with a need-to-know-theinformation-for-care reasons have access to the medical record. The patient has a legal
right to control access to personal information, and the nurse should not give the sister
the chart for review, even with the patient present. It is best to be honest and explain the
patient’s legal rights rather than avoiding the subject. - Which are reasons that accurate documentation in the medical record is important?
(select all that apply)
a. remimbursement for care
b. evidence of care provided
c. communication between health care providers
d. nonlegal documentation of a nurse’s actions
e. promotion of continuity of care
Rationale:
Documentation in the medical record is important for reimbursement for care, for
providing a record of services, for communication between providers, and for promoting
continuity of care. The record is a legal document, not a non-legal document.
- Which note is an example of the S in SBAR?
a. Patient resting; pain was rated 3 of 10 1 hour after receiving narcotic analgesic.
b. Patient was admitted on evening shift with a fractured right femur after a fall at home.
c. Patient’s pain was rated 8 of 10 before administration of narcotic pain medication.
d. Assess pain ever 2 hours, continue pain medication as prescribed, and provide
backrub.
Rationale:
The S in SBAR stands for situation. In this case, the patient is resting, and the pain is
rated 3 of 10 one hour after receiving a narcotic analgesic. Describing the admission
reason and time provides the background (B). Assessment (A) of this patient revealed
pain rated 8 of 10 before giving pain medication. The nurse’s recommendation (R) is
that pain should be assessed every 2 hours and that pain medications should be given
as prescribed. - Which attributes are important in nursing documentation? (select all that apply)
a. Inconsequentiality
b. Timeliness
c. Relevancy
d. Accuracy
e. Factual basis
Rationale:
Documentation should be completed in a timely manner, be relevant and concise, and
be accurate and factual. Inconsequentiality suggests a lack of importance, and
documentation is an important part of patient care and nursing responsibility
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