Which data in a medical record would inform the nurse that a PRN pain medication can be administered to the patient?
The medication administration record
... [Show More] and the nursing assessment notes from the last shift indicate the patient's level of comfort.
Which information in a patient's medical record will help a nurse plan and manage the patient's pain?
Physician orders
A patient completes the course of treatment for tuberculosis and is ready to be discharged home. Which instructions should be included in the patient's discharge education?
Importance of completing the medication prescribed
A mother brings her child to the emergency department after noticing the child had trouble breathing, refused breastfeeding, and no urine in the diaper within the last eight hours. The provider suspects respiratory syncytial virus and admits the infant to the hospital. How will data in the medical record inform the decision to select appropriate infection-control precautions?
The data will identify the pathogen causing the patient's symptoms
A nurse admits an infant with a severe hacking cough, vomiting, and a fever for the past two weeks. Which data in the electronic medical record (EMR) informs the decision to implement infection-control precautions?
The nasopharyngeal swab culture results indicate the patient is positive for Bordetella pertussis.
A patient is admitted to the hospital with a painful rash on the left side of the face. The provider orders the patient to be placed on contact precautions. Which data in the electronic health record (EHR) informed the decision to implement contact precautions?
The skin culture results indicate the presence of the varicella-zoster virus.
After a patient's assessment, a nurse observes a decrease in respiration and wheezing on auscultation. Which data set in the medical record informs the decision to implement the ineffective airway clearance nursing care plan?
The radiology report impression indicates pulmonary infiltrates and the nursing assessment indicates a decrease in respirations.
The health administrator at a clinic observes an increase in the number of patients with a complaint of difficulty breathing, fatigue, and loss of appetite. Which data in the electronic medical record will provide a cross-reference to the impacted patient population?
Patient demographic records
Which view in the electronic medical record (EMR) confirms a patient's blood pressure is stabilizing?
Graphical trending
After a patient's initial assessment, a nurse observes an increase in edema, bilateral crackles, and persistent cough. Which data set in the medical record from the last shift informs the decision to implement the fluid volume overload care plan?
Nursing flowsheet and intake and output record
Which data set in the electronic medical record (EMRs) will assist in evaluating the number of positive influenza tests at a facility within the past year?
Laboratory records
During the evening shift, a nurse notices a significant change in a patient's blood pressure as compared to the morning shift. Which 24-hour trend information in the electronic medical record will help the nurse further evaluate and manage the patient's blood pressure?
The intake and output record
Pharmacy adds a field into the medication administration record to document the lot number when a chemo medication is administered, but fails to communicate this to the nurse responsible for the medication administration documentation. What is a consequence of this action?
Pharmacy cannot determine if there is a problem with a medication batch.
A nurse thinks the electronic health record (EHR) has too many documentation fields, making it difficult to know where to document some items. As a result, the nurse uses the notes instead or in addition to documenting in a specific field in the health record. What is the least significant impact of this action?
Duplicate documentation appears multiple times in the chart.
A nurse is working in a medical-surgical unit assigned care for five patients. The nurse has many tasks to accomplish during a shift. Which informatics solution assists in ensuring these tasks are accomplished?
Electronic checklist
Which barrier to healthcare informatics use does the HITECH Act aim to reduce?
Financial
A project team is moving a hospital from using paper charting to using an electronic health record for documentation. How should the project team roll out the software to reduce the impact on the hospital?
A large stand-alone department should go live first.
Which patients are ideally positioned to fully engage in their care?
Patients that are recovering well after a full night of sleep.
A nurse is teaching a patient-centered health education course at a hospital. As an informatics nurse leveraging technology to help improve patient understanding, which learner would be more likely to have a low health literacy and require more focus?
An elderly person
What is true about improving health literacy?
Improving health literacy leads to better patient outcomes.
A nurse assists with implementing a new remote patient monitoring (RPM) system for collecting patient data, which improves patient outcomes. Which task is a high priority for an informatics clinician when implementing a new technology for patient data collection?
Identify and define the goal of the technology
Patient use of technology has increased dramatically. While patients are more active in their care, a nurse notes they are often misinformed or obtain information that is inaccurate. Which recommendation should the nurse give to ensure education is accurate?
List credible education resources for the patient's research.
What does the informatics nurse recommend to increase attendance to follow-up appointments?
Automated text or email reminders
While reviewing electronic nursing documentation, a nurse identifies that a patient's vital signs have declined since the previous shift. Which health information system assisted in this identification?
Electronic health record (EHR)
The nurse manager of an outpatient laboratory clinic is investigating decreased patient satisfaction scores and cited delays in receiving lab results. The first step is to review testing turnaround times for the clinic. Which health information system (HIS) should the nurse manager review for this data?
Laboratory information systems (LIS)
What is a patient safety benefit of a pharmacy information system (PIS)?
Alerts regarding allergies and interactions
Standardized terminology was implemented to promote interoperability across electronic health records (EHRs). Which terminology is specific to laboratory tests, orders, and results?
LOINC
A nurse performing patient discharge from a facility provides a continuity of care document (CCD) to a patient and explains the document and contents at discharge. What is a benefit provided by the CCD?
It provides a summary of care to patients and clinicians.
What are patient portals?
Patient portals are facility-owned and associated with an electronic health record.
A hospital notes a decreased use of barcoded medication administration (BCMA) along with an increase in medication errors. What should be the next course of action?
Monitor BCMA usage reports for trend [Show Less]