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

thoroughly. The patient may not have verbalized pain but could still be experiencing it.

B. The patient states, "It feels like a knife stabbing me.": This documents subjective data verbatim using the patient’s exact words, which is best practice for accuracy and clarity.

C. "Lump diminished.": This lacks specificity—the exact size, texture, or other changes should be documented using precise measurements (e.g., “Lump decreased from 3 cm to 2 cm”).

D. "Patient's condition much better today than yesterday.": This is too vague and lacks measurable indicators of improvement (e.g., vital signs, pain level, mobility).

A. the specific time of all sudden changes in the patient's condition B. the period the shift covers C. every 2 hours D. every hour on the hour

Correct Answer is A

Explanation

A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.

B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.

C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.

D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is an example of good charting?

Correct Answer is B

Explanation

When documenting events in a patient's chart, the nurse should chart:

Correct Answer is A

Explanation

Identify the two primary methods used to collect data:

To what does objective data refer when assessing a patient?

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:

Who should document care in the patient record?

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

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

Which of the following statements is correct about abbreviations?

The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date it is determined that a/an: