Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

ethically can look at a friend's chart to see the diagnosis

shares information from a chart to protect a friend

knows that only the Patient's Bill of Rights advocates confidentiality

reads charts only for professional reasons

Answer and Explanation

The Correct Answer is D

A. Ethically can look at a friend's chart to see the diagnosis: Accessing a patient’s chart without a legitimate medical reason violates HIPAA and patient confidentiality laws.

B. Shares information from a chart to protect a friend: Confidentiality applies regardless of personal relationships. Unauthorized sharing of patient information is illegal and unethical.

C. Knows that only the Patient’s Bill of Rights advocates confidentiality: Multiple regulations, including HIPAA, protect patient confidentiality, not just the Patient’s Bill of Rights.

D. Reads charts only for professional reasons: Nurses can only access patient records when directly involved in care. Unnecessary access is a breach of confidentiality.

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Correct Answer is C

Explanation

A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.

B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.

C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.

D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.

A. CNA B. Technician C. RN D. LPN/LVN

Correct Answer is C

Explanation

A. CNA (Certified Nursing Assistant): CNAs assist with basic patient care (e.g., hygiene, vital signs) but do not perform assessments or make nursing diagnoses.

B. Technician: Technicians perform specific tasks (e.g., drawing blood, ECGs) but do not analyze patient data for diagnosis.

C. RN (Registered Nurse): The RN is responsible for analyzing and interpreting data, identifying nursing diagnoses, and developing the care plan.

D. LPN/LVN (Licensed Practical/Vocational Nurse): LPNs/LVNs can collect data but cannot make a nursing diagnosis, which is the RN’s role.

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Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Who should document care in the patient record?

Correct Answer is C

Explanation

Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:

Correct Answer is C

Explanation

The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

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:

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

Which of the following assists the nurse in the identification of nursing diagnoses?

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?

One benefit of computerized charting is that:

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?