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Electronic Health Records And Nursing By Gartee & Beal – 
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Gartee, Electronic Health Records and Nursing, 1e
Chapter 1

Question 1

Type: MCSA

Which entity first identified capturing data at the point of care as a key criterion for an EHR?

  1. Health Insurance Portability and Accountability Act (HIPAA)
  2. Institute of Medicine (IOM)
  3. Computer-based Patient Record Institute (CPRI)
  4. Health Information Technology for Economic and Clinical Health (HITECH) Act

Question 2

Type: MCSA

Which of the following is the best definition of electronic health records?

  1. Any information that relates to the past, present, or future physical condition of a person that is stored in an electronic format.
  2. The portions of a client’s medical records that are stored in a computer system as well as the functional benefits derived from having an electronic health record.
  3. Client information that is stored electronically and may be accessed by both the client and the client’s healthcare providers on demand.
  4. Any healthcare information that is stored by computer.

 

Question 3

Type: MCSA

The ONC developed which of the following strategies to meet their goal of informing clinical practice?

  1. Fostering regional collaborations
  2. Encouraging use of PHR
  3. Accelerating research and dissemination of evidence
  4. Promoting EHR diffusion in rural and underserved areas

 

Question 4

Type: MCSA

Why would a small primary care practice need to know about the HITECH Act?

  1. Because it makes funding available to help the practice implement a certified EHR
  2. Because it will reduce Medicare payments by five percent if the use of paper charts continue to be used in 2013
  3. Because it offers financial incentives for implementing an EHR before 2015
  4. Because it requires medical practices to offer telemedicine to clients by 2020

 

Question 5

Type: MCSA

Which of the following is not one of the IOM criteria for EHRs?

  1. Connectivity between multiple care providers
  2. Management of administrative processes and reporting
  3. Statistical collection and reporting related to population health
  4. Capture data at the point of care

 

Question 6

Type: MCSA

The nurse reviews the client registration form, and asks for more detail about the chief complaint, which is:

  1. A summary of the client’s symptoms
  2. A record of the client’s vital signs
  3. The main reason a client seeks care
  4. The nurse’s assessment of what is wrong with the client

 

Question 7

Type: MCSA

The nurse is caring for a client with upper respiratory and sinus symptoms. The provider writes a prescription on a prescription pad. . Which of the following is reasonable to infer about the client records at the provider’s office based on this interaction?

  1. They may be either paper or electronic because EHR systems require a handwritten prescription for the medical chart.
  2. They are electronic records but the software does not support electronic prescription submission.
  3. They are paper records because electronic records require electronic submission of prescriptions.
  4. They may be either paper or electronic but your doctor simply prefers to write out her or his prescriptions.

 

Question 8

Type: MCSA

Which of the following is not true about an inpatient chart?

  1. It only contains information related to the client’s current stay.
  2. Its central element is the physician’s exam note.
  3. It includes more information than an outpatient chart.
  4. It includes nurse’s notes that indicate the client’s response to treatment.

 

Question 9

Type: MCSA

Which of the following is a characteristic of an EHR system used by a medical office?

  1. It incorporates computer systems from many different vendors.
  2. It is the principal electronic medical record.
  3. It must be accessible to any specialists who are also treating the client.
  4. It requires clinicians to use an interface to view data from different systems.

 

Question 10

Type: MCSA

The nurse demonstrates which of the following as an example of point-of-care documentation?

  1. A nurse enters a client’s vital signs into the client’s record at the end of the shift.
  2. A transcriptionist types an encounter note and sends it to the physician.
  3. A nurse practitioner enters the encounter data during the client’s visit.
  4. A nurse practitioner creates an exam note from memory while the client gets dressed.

 

Question 11

Type: MCSA

One drawback of using an EHR on a tablet PC that is not a problem on a laptop is that it:

  1. is easy to drop.
  2. runs on batteries.
  3. is harder for IT departments to update.
  4. lacks a keyboard.

Question 12

Type: MCSA

Both the IOM and CPRI share which of the following EHR criteria recommendations?

  1. Data capture at the point of care
  2. Electronic communication and connectivity
  3. Provision of decision support
  4. Client support

 

Question 13

Type: MCSA

The nurse explains to a client that one of the improvements that point of care documentation provides in the delivery of healthcare is:

  1. It saves time and money by eliminating the cost of dictation and transcription.
  2. It prevents a clinician from signing an encounter note before the client leaves the office.
  3. It ensures that all information required for referrals is available immediately.
  4. It gives the client a chance to make corrections to his or her medical record.

 

Question 14

Type: MCSA

Which of the following best defines the term eligible professional?

  1. Any clinician who works directly with clients when providing care and is therefore bound by HIPAA mandates.
  2. Anyone who has been granted access to protected health information in electronic form.
  3. A credentialed healthcare professional that is in good standing with a medical board and qualified to practice in a state.
  4. A healthcare provider who is considered entitled to receive incentive payments under the HITECH Act.

 

Question 15

Type: MCSA

Which of the following considered an optional, rather than a core, meaningful objective for hospitals when fulfilling the CMS meaningful use criteria?

  1. CPOE
  2. Drug-formulary checks
  3. Maintain active medication list
  4. Record smoking status for clients 13 years or older

 

Question 16

Type: MCSA

Which of the following certifies an EHR system?

  1. ONC-ATCB
  2. CPRI
  3. CHCS II
  4. AHIMA

 

Question 17

Type: MCSA

Which of the following statements about electronic health records is true?

  1. The idea for electronic health records first originated with the Health Insurance Portability and Accountability Act.
  2. The Computer-based Patient Record Institute outlined eight core functions that any EHR should be able to perform.
  3. It has primarily been physicians who have led the charge in the impetus behind developing a national EHR system.
  4. The HITECH Act is promoting the widespread adoption of electronic health records.

 

Question 18

Type: MCSA

Which of the following organizations created a strategy that tied purchase of group health insurance benefits to quality care standards?

  1. AHIMA
  2. Leapfrog Group
  3. Kaiser Permanente
  4. Agency for Healthcare Research and Quality

 

Question 19

Type: MCSA

Which of the following is not considered part of the workflow in a medical office that uses an EHR system?

  1. The workflow process begins when the client requests an appointment.
  2. The clinician dictates her exam notes at the conclusion of the client encounter.
  3. The client discusses his symptoms with the nurse.
  4. The client leaves the office with a printed copy of the encounter.

 

Question 20

Type: MCSA

Which of the following is not true of speech recognition software?

  1. Recognizes verbal commands to operate the software.
  2. Recognizes the patterns in human speech as words and turns them into text.
  3. Replaces the nurse with a computer software program.
  4. Frequently used in specialties such as radiology and pathology.

 

Question 21

Type: MCMA

The nurse explains to the client who is being admitted to the acute care facility for the third time in six months that the results management function of the EHR allows providers to:

Standard Text: Select all that apply.

  1. recognize and treat problems more quickly
  2. reduce the number of tests ordered
  3. recognize abnormal results more quickly
  4. utilize established critical links between providers and providers and clients to improve care coordination
  5. reduce the number of errors in medication dose and frequency

 

Question 22

Type: MCMA

The nurse uses the electronic communication function of the EHR to:

Standard Text: Select all that apply.

  1. Communicate with the pharmacy
  2. email clients and providers
  3. Communicate with the laboratory
  4. View prevention guidelines
  5. Review drug-drug interactions

 

Question 23

Type: MCSA

The nurse understands that the primary force driving the adoption of EHR as a standard of practice is:

  1. Health costs
  2. Medical errors
  3. Clients relocation
  4. Provider request

 

Question 24

Type: MCMA

The client is complaining to the nurse about the need for a computer in the examination room. The nurse explains that the EHR is important because:

Standard Text: Select all that apply.

  1. Legibility
  2. The ability to search the records is facilitated
  3. Sharing information
  4. Ability to locate records
  5. Storage needs

 

Question 25

Type: MCSA

In the office that uses paper charts, how many times is the paper chart touched by personnel, including the provider, during a visit for an upper respiratory infection that requires a chest x-ray?

  1. 3 or less
  2. at least 6
  3. 5 or less
  4. 4

 

Question 26

Type: MCSA

The major difference between the outpatient and inpatient client record is:

  1. Each client has his or her own chart
  2. The quantity of data in an outpatient chart is much larger
  3. The central element of the inpatient chart is the physician’s exam note
  4. The inpatient chart contains only information related to the current stay

 

Question 27

Type: MCSA

The benefits of using a computer workstation include:

  1. Uses minimal space
  2. reliability
  3. wireless networking is faster
  4. mobility

 

Question 28

Type: MCSA

One advantage of the workstation over a tablet PC is:

  1. Portability
  2. Screen resolution
  3. Handwriting recognition
  4. Mouseless interface

 

Question 29

Type: MCMA

Laptop computers have which of the following disadvantages compared to the workstation:

Standard Text: Select all that apply.

  1. Security concerns
  2. Rapid obsolescence
  3. Portability
  4. Battery life
  5. Accidental damage

 

Question 30

Type: MCSA

The need for EHR and better connectivity between EHR systems is important because:

  1. Physicians want to streamline client care
  2. Providers need access to a client’s medical history in case of emergency
  3. It is difficult to get care on weekends
  4. It is mandated by the ONC

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 2

Question 1

Type: MCSA

Which of the following is not a functional benefit for an EHR as defined by the IOM?

  1. Trend analysis
  2. Health maintenance
  3. Discrete data
  4. Alerts

 

Question 2

Type: MCSA

Which of the following is an example of a digital image that may be part of an electronic medical record?

  1. Fielded data
  2. Coded data
  3. Transcribed exam notes
  4. Annotated drawings

 

Question 3

Type: MCSA

Which of the following statements is true about discrete data that is stored in an EHR system?

  1. A person is needed to interpret its meaning.
  2. It must first be imported from outside text files.
  3. It requires little storage space.
  4. It is only useful if it is codified.

 

Question 4

Type: MCMA

Text data that is stored in an EHR system is least useful for performing which of the following functions?

Standard Text: Select all that apply.

  1. Decision support
  2. Trend analysis
  3. Research
  4. Diagnosis
  5. Alerts

 

Question 5

Type: MCSA

Which of the following is an example of a result finding?

  1. white male
  2. 20120331
  3. gall bladder
  4. normal urine protein

 

Question 6

Type: MCSA

Which of the following is not one of the six main categories that the MEDCIN nomenclature uses to organize findings?

  1. Body Structure
  2. Symptoms
  3. Physical Examination
  4. Therapy

 

Question 7

Type: MCSA

What is the NANDA-I code set used to categorize?

  1. Laboratory test results
  2. Biomedical information
  3. Nursing diagnoses
  4. Point-of-care documentation

 

Question 8

Type: MCSA

You have just imported an x-ray for a client into an image system; this means:

  1. the image has been successfully cataloged.
  2. you need to use OCR software to catalog this image.
  3. you need to complete the cataloging process by adding the client’s name.
  4. you need to enter identifying data about the document into the computer.

 

Question 9

Type: MCSA

Which of the following is not true of a Picture Archival Communication System (PAC)?

  1. It imports digital images into the EHR system.
  2. It associates images with the client EHR record.
  3. It is separate from the EHR system.
  4. It is used to archive diagnostic images.

 

Question 10

Type: MCSA

Your medical office is implementing an EHR system and needs to add numerous paper charts into the new document/image system. The best course of action would be to:

  1. scan all of the printed pages into the new system.
  2. keep the paper charts, but begin entering all new information electronically.
  3. import the word processing files from any transcribed dictation as text records.
  4. hire transcriptionists to retype all of the old information into the EHR.

 

Question 11

Type: MCSA

A text file would be produced for upload to an EHR in which of the following examples?

  1. A medical assistant scans and catalogs a copy of a client’s test results.
  2. A clinician selects a protocol through a client chart at the point-of-care.
  3. A radiology technician links to a copy of an X-ray stored in a PAC.
  4. A medical transcriptionist types exam notes using a word processor.

 

Question 12

Type: MCSA

Which of the following statements about imported text data is false?

  1. The text data is searchable by computer.
  2. The text data may be incorporated into the EHR system.
  3. The text document will dynamically resize itself when viewed on a handheld device.
  4. The text data is codified by the EHR once it has been imported.

 

Question 13

Type: MCSA

Which of the following standards would enable a hospital that uses many different systems to integrate data from all of these systems in a cohesive way?

  1. DICOM
  2. HL7
  3. PAC
  4. IMH

 

Question 14

Type: MCSA

Which of the following is an example of trend analysis provided by an EHR?

  1. An article on from a professional medical journal
  2. A generic equivalent to a brand name drug
  3. A graph showing a client’s cholesterol levels over time
  4. A message automatically generated from the data

 

Question 15

Type: MCSA

Which of the following would the nurse not consider a benefit of client-entered data?

  1. The client is an authority on the symptoms he experienced when an illness started.
  2. The client can enter accurate information about her social and family history.
  3. The client can review and make corrections to previous entries made by medical staff.
  4. The client can comment on the success of previous treatments that were recommended by the clinic.

 

Question 16

Type: MCSA

An alert that warns a provider that a brand name drug is not covered by a client’s insurance plan is an example of a(n):

  1. ABN alert.
  2. formulary alert.
  3. nonaction alert.
  4. electronic lab order system alert.

 

Question 17

Type: MCSA

Jenna has a penicillin allergy. Which of the following alerts in an EHR would detect this allergy?

  1. DUR
  2. PDR
  3. ABN
  4. HL7

 

Question 18

Type: MCSA

A parent receives a letter in the mail from the pediatrician that their child is due to receive certain immunizations. This is an example of which functional benefit of codified EHR data?

  1. Trend analysis
  2. Health maintenance
  3. Alerts
  4. Decision support

 

Question 19

Type: MCSA

What is a medical protocol?

  1. Treatment recommendations for the use of certain drugs
  2. A standard plan of therapy established for different conditions
  3. Evidence-based guidelines used for client diagnosis
  4. Medication dosing guidelines based on test results

 

Question 20

Type: MCSA

An insurance billing code represents a:

  1. client’s symptoms.
  2. nurse’s observations.
  3. service that was rendered.
  4. treatment plan.

 

 

Question 21

Type: MCMA

Which of the following are examples of digital images?

Standard Text: Select all that apply.

  1. scanned documents
  2. diagnostic images
  3. transcription notes
  4. fielded data
  5. coded data

 

Question 22

Type: MCMA

The client is entering data into the EHR. What type of data does the client commonly enter?

Standard Text: Select all that apply.

  1. family history
  2. current symptoms
  3. vital signs
  4. medical history
  5. medications

 

Question 23

Type: MCMA

The nurse is caring for a client who has a history of bleeding, and has been treated with multiple transfusions. Which of the following functional benefits will assist the nurse in evaluating the client’s progress?

Standard Text: Select all that apply.

  1. trend analysis
  2. health maintenance
  3. alerts
  4. decision support
  5. population health reporting

 

Question 24

Type: MCMA

The nurse is caring for an elderly client. What types of preventive screening might be entered into the EHR to complete the client’s record?

Standard Text: Select all that apply.

  1. Date of last colonoscopy
  2. Date of last mammogram
  3. Date of last TB test
  4. Date of last influenza vaccine
  5. Date of last eye exam

 

 

Question 25

Type: MCSA

The nurse is reviewing the medication record of a client. Which of the following EHR categories will be helpful in determining potential medication interactions?

  1. client entered data
  2. decision support
  3. health maintenance
  4. trend analysis

 

Question 26

Type: MCMA

The nurse understands that a codified EHR is important because:

Standard Text: Select all that apply.

  1. searching the EHR is faster
  2. treatment identification is vague
  3. clinicians findings are precise
  4. data can be exchanged
  5. it keeps information private

 

Question 27

Type: MCMA

The nurse explains the purpose(s) of the drug utilization review program in the EHR as including:

Standard Text: Select all that apply.

  1. possible drug interactions
  2. possible drug duplication
  3. contraindications for current diagnosis
  4. dosage guidelines
  5. drug cost

 

Question 28

Type: MCMA

The nurse identifies the following steps in cataloging images:

Standard Text: Select all that apply.

  1. scanning documents
  2. importing images into an image system
  3. identifying client allergies
  4. tying image to correct client
  5. identifying provider

 

Question 29

Type: MCMA

The health care team might want to import client data into the EHR from what types of devices?

Standard Text: Select all that apply.

  1. vital sign monitors
  2. cardiac monitors
  3. glucose meters
  4. pedometers
  5. fetal monitors

 

Question 30

Type: MCMA

The EHR can assist the nurse in care planning by:

Standard Text: Select all that apply.

  1. identifying diagnoses
  2. identifying intervention standards
  3. identifying medication reactions
  4. identifying outcome standards
  5. identifying allergies

Gartee, Electronic Health Records and Nursing, 1e
Chapter 3

Question 1

Type: MCSA

Which of the following is true about the login you use for the Student Edition software?

  1. It must be kept secret.
  2. It creates a permanent record of your use of the software.
  3. It is unique to you.
  4. It serves as your electronic signature.

 

Question 2

Type: MCSA

In which section of the Student Edition software is the Hx tab located?

  1. Encounter View Pane
  2. Medcin Nomenclature Pane
  3. Menu Bar
  4. Entry Details

 

Question 3

Type: MCSA

Which of the following is not an example of a function menu in the Student Edition software?

  1. Options
  2. Graph
  3. Encounter
  4. Enter

 

Question 4

Type: MCSA

Where within the Student Edition software can you locate a finding associated with its appropriate ICD-9-CM code?

  1. Entry Details
  2. Note View
  3. Sx tab
  4. Outline View

 

Question 5

Type: MCSA

When using the Student Edition software, what is the first step in every encounter once you have logged in?

  1. Creating a new encounter
  2. Selecting a Patient
  3. Assigning a finding
  4. Verifying client information

 

Question 6

Type: MCSA

The Sx tab on the Nomenclature pane is associated with which component of the SOAP format?

  1. Subjective
  2. Objective
  3. Assessment
  4. Plan

 

Question 7

Type: MCSA

You are viewing findings in the Medcin Symptoms tab and notice that “facial twitching” has neither a small plus sign nor a small negative sign beside it. What does this mean?

  1. This symptom is not the right match for the client.
  2. Facial twitching is the main title for a new subcategory.
  3. The tree for this finding has been collapsed.
  4. This is the most specific finding available for symptom.

 

Question 8

Type: MCSA

You are trying to locate the client Robert Smith in the Student Edition Patient Selection window. Which of the following would be the quickest way to locate his record?

  1. Typing his patient identification number
  2. Typing the client’s first name and last name
  3. Scrolling through the list of client names
  4. Entering the client’s last name, followed by R

 

Question 9

Type: MCSA

What is the main purpose of an EHR system that is based on the Medcin nomenclature?

  1. To document clinical notes in a codified electronic medical record
  2. To allow providers to write prescriptions electronically
  3. To perform drug utilization reviews and send alerts
  4. To provide both clients and healthcare providers equal access to information

 

Question 10

Type: MCSA

Which of the following statements is not true about an encounter note?

  1. It often includes data that was entered by different healthcare professionals.
  2. It is a record of the clinical findings from a client examination.
  3. It reflects findings from an exam that occurred on a specific date.
  4. It is a longitudinal record of the care a client has received.

 

Question 11

Type: MCSA

Under what circumstances is a new encounter created for a client?

  1. When a client introduces new symptoms during an office visit
  2. When a provider orders blood work for a client as part of an annual physical exam
  3. When a client calls a medical office with a billing inquiry
  4. When a client visits her nurse practitioner with symptoms of the flu

 

Question 12

Type: MCSA

A client tells you that he has been having back pain for over a month. Later in the exam, he remembers the pain seems to be getting worse. How would you record this finding information in the EHR?

  1. Back-related symptoms
  2. Back pain, episodes recently worse
  3. Chronic/recurring, back pain
  4. Back pain, chronic/recurring, episodes recently worse

 

Question 13

Type: MCSA

All of the following Entry Details fields are stored in the EHR as fielded data except:

  1. Modifier
  2. Free text
  3. Value
  4. Episode

 

Question 14

Type: MCSA

Why is the first item in each drop-down list within the Entry details fields a blank?

  1. To enable the user to search
  2. To enter free text
  3. To clear certain Entry Details fields
  4. To modify a selected finding

 

 

Question 15

Type: MCSA

Which of the following is not an advantage of the free-text entry window?

  1. The window is large enough to allow a clinician to type a longer note.
  2. The text entered in this window is stored as fielded data.
  3. The clinician can use a spell checker to proofread her text.
  4. It includes an insert text feature that helps save typing time.

 

Question 16

Type: MCSA

Which of the following is the Medcin tab used for “tests performed”?

  1. Sx
  2. Rx
  3. Tx
  4. Dx

 

Question 17

Type: MCSA

Which of the following is the Medcin tab for “treatments”?

  1. Sx
  2. Rx
  3. Tx
  4. Dx

 

Question 18

Type: MCSA

Where are the Entry Details fields located in the Student Edition software?

  1. In the right pane of the window
  2. At the bottom portion of the screen
  3. In the left pane of the window
  4. Along the top portion of the screen

 

Question 19

Type: MCSA

Where is the Note View tab within the main window of the Student Edition software located?

  1. The Medcin Nomenclature Pane
  2. The Encounter View Pane
  3. The Menu Bar
  4. Outline View

 

Question 20

Type: MCSA

If you are entering information about tests that have been performed on a client, you are most likely to select which tab in the Nomenclature Pane?

  1. Sx
  2. Px
  3. Tx
  4. Rx

 

Question 21

Type: MCMA

The following steps are followed when signing in to the Medcin Student Edition software:

Standard Text: Select all that apply.

  1. Enter name or student ID
  2. Enter social security number for identification
  3. Double click on the Medcin icon
  4. Click the cancel button
  5. Click on Select

 

Question 22

Type: MCSA

The nurse is preparing to enter a client encounter. The first step in every encounter is to Select:

  1. New Encounter from the Select menu
  2. Client from the select menu
  3. Existing Encounter from the Select menu
  4. Enter from the Menu bar

 

Question 23

Type: MCSA

The nurse is caring for a client who has been to the office several times for a recurring UTI. The appropriate action when beginning the office visit is to:

  1. Edit an existing encounter to enter follow-up information
  2. Create a new encounter
  3. Order a new urinalysis
  4. Review test results

 

Question 24

Type: MCSA

The nurse has checked the client’s vital signs, and performed an EKG. This information would be documented using which tab?

  1. Sx
  2. Tx
  3. Rx
  4. Dx

 

Question 25

Type: MCSA

The client reports pain in the left leg. During the course of the encounter, the client states “I am so confused. It is my right leg.” The appropriate action for the nurse to take is:

  1. Delete the encounter
  2. Create a new encounter
  3. Edit the existing encounter
  4. Sign out without saving the information and start over

 

Question 26

Type: MCMA

The client has been seen several times for a recurring UTI, having been treated for three weeks without relief. Appropriate documentation in the Sx field includes:

Standard Text: Select all that apply.

  1. Adding a status comment
  2. Adding a free text comment
  3. Adding a diagnosis
  4. Adding to the nursing care plan
  5. Editing a previous encounter

 

Question 27

Type: MCSA

The nurse is recording a client’s height and weight. The appropriate tab to click is the:

  1. Select
  2. Encounter
  3. Forms
  4. Nursing

 

Question 28

Type: MCMA

The nurse is preparing to enter the client’s chief complaint of burning on urination. The appropriate actions to take include:

Standard Text: Select all that apply.

  1. Locate the button on the Toolbar labeled ROS
  2. Locate the button on the Toolbar labeled Chief
  3. Enter text in the chief Complaint window
  4. Click the mouse on Enter to record the note
  5. Select the appropriate Chief complaint from a list

 

Question 29

Type: MCSA

Nursing care is entered in the:

  1. Rx tab
  2. Forms view
  3. Px tab
  4. Nursing tab

 

Question 30

Type: MCMA

The nurse is reviewing a free text entry describing a test that is scheduled for a client. The advantages to using a free text entry instead of a Status entry include:

Standard Text: Select all that apply.

  1. Free text is easier
  2. Free text is stored as fielded data
  3. Status adds informational text to the finding
  4. Status is stored as fielded data
  5. A status entry is a better choice

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 4

Question 1

Type: MCSA

Which of the following should be typed in the field of the log in screen for the Student Edition software?

  1. Your course code
  2. Your school’s name
  3. Your name or student ID
  4. Your e-mail address

 

Question 2

Type: MCSA

You want to start the Student Edition software but do not see the Medcin icon. What should you do?

  1. Reboot your computer, and then try opening the software again.
  2. Check to make sure your screen is maximized.
  3. Hit Exit on the Menu bar to close the software, and then retry opening it.
  4. Click on the Start button, and then look in Programs to find it.

 

Question 3

Type: MCSA

You are creating a new encounter for the client Davida Johnson. At what point do you select “New Encounter” for this client when using the Student Edition software?

  1. After you have located and clicked on the client’s name in the Patient Selection window.
  2. Not until the physician has entered a diagnosis for the client.
  3. After you have set the date and time for the New Encounter.
  4. While you are setting up the appointment for the client.

 

Question 4

Type: MCSA

“Annual checkup” would be an example of a(n):

  1. Alert
  2. Reason for the encounter
  3. Client symptom
  4. Treatment plan

 

Question 5

Type: MCSA

When creating a new encounter using the Student Edition software, where do you enter the chief complaint?

  1. Sx tab
  2. Vital signs form
  3. Note view
  4. Dx tab

 

Question 6

Type: MCSA

A client tells you that the medication he’s been taking to control his allergies is not working well. Which Entry Details field would you record this information?

  1. Episode field of Entry Details
  2. Duration field of Entry Details
  3. Status field of Entry Details
  4. Onset field of Entry Details

 

Question 7

Type: MCSA

Under what tab in the Student Edition software would you expect to find “Benign syndromes”?

  1. Dx
  2. Sx
  3. Rx
  4. Tx

 

Question 8

Type: MCSA

You have entered information about a client’s vital signs using the vital signs form. Where will this information appear on the encounter note?

  1. Assessment
  2. History of present illness
  3. Physical findings
  4. Chief complaint

 

Question 9

Type: MCSA

Within which tab would you expect to locate the finding “Examination of Scalp?”

  1. Px
  2. Sx
  3. Rx
  4. Tx

 

Question 10

Type: MCSA

A client provides a lengthy description of how her new restricted diet is helping to control her diabetes. You would use which of the following to record this information most effectively?

  1. Result field within Entry Details
  2. Finding Note window
  3. Free-text field within Entry Details
  4. Status field in the Px tab

 

Question 11

Type: MCSA

Which of the following would not be an example of a social history finding within the Student Edition software?

  1. Tobacco use
  2. Trouble coping with change
  3. Daily alcohol consumption was 1, 6oz. drink per day
  4. Drug allergies

 

Question 12

Type: MCSA

When you have finished an exercise using the Student Edition software, you

  1. do not need to save it because the software saves it automatically.
  2. need to output your work to a printer or file, unless instructed otherwise.
  3. should always print a hard copy of each exercise.
  4. will export your file to a Word document, and then e-mail it to your instructor.

 

Question 13

Type: MCSA

Which of the following statements about a printed encounter note for a client is correct?

  1. The Chief complaint and the Assessment contain the same information.
  2. Sections on the form without any information appear blank.
  3. The History of present illness section contains information on symptoms
  4. The client must review the encounter note before the physician signs it.

 

Question 14

Type: MCSA

Within which tab would you set a client’s cognitive functions to abnormal?

  1. Rx tab
  2. Px tab
  3. Sx tab
  4. Dx tab

 

Question 15

Type: MCSA

When printing or exporting encounter notes using the Student Edition software, remember that you:

  1. can only print or export your work at the completion of an exercise.
  2. need to use the Print icon on the computer.
  3. will require access to a network printer or the Internet.
  4. should have your printed note or exported file in hand before exiting.

 

Question 16

Type: MCSA

The past medical history for a client would most likely include which of the following details?

  1. Current blood pressure
  2. Insurance coverage
  3. Age at time of exam
  4. Previous surgeries

 

Question 17

Type: MCSA

The nurse observes local swelling in a client’s leg. How would this finding be indicated in the Px tab of the Student Edition?

  1. (Blue button) Lower extremity
  2. (Red button) Localized
  3. (Red button) Edema
  4. (Blue button) Leg pain

 

Question 18

Type: MCSA

A nurse practitioner diagnoses a client with a rhinitis and prescribes fluids and rest. To locate this assessment in the Dx tab, where would you begin?

  1. Nose
  2. ENT Disorders
  3. Instructions for Client
  4. Rhinitis

 

Question 19

Type: MCSA

Under which tab is the client’s plan for therapy and treatment recorded?

  1. Rx tab
  2. Px tab
  3. Sx tab
  4. Dx tab

 

Question 20

Type: MCSA

A client who has been in a minor car accident does not show any signs of a lower back injury. Where would you enter this information in the Student Edition software?

  1. Rx tab
  2. Px tab
  3. Sx tab
  4. Dx tab

 

Question 21

Type: MCMA

Which steps are necessary to login to the Student Edition software?

Standard Text: Select all that apply.

  1. Start the Student Edition software
  2. Locate the Start icon on the desktop
  3. Locate the Medcin icon on the desktop
  4. Login using the student name
  5. Select a patient

 

Question 22

Type: MCMA

The selection of the correct client is accomplished by:

Standard Text: Select all that apply.

  1. Click the word “Enter”
  2. Click the word “Select”
  3. Scroll to the appropriate client
  4. Click the word “Browse”
  5. Click the word “Details”

 

Question 23

Type: MCSA

The appropriate option to click when preparing to enter a client’s vital signs is:

  1. Encounter
  2. Forms
  3. Nursing
  4. Enter

 

Question 24

Type: MCMA

The client is being admitted to the Emergency Department. The nurse takes the following steps to document the encounter:

Standard Text: Select all that apply.

  1. Click Enter on the Medcin Student edition toolbar
  2. Click Select on the Medcin Student edition toolbar
  3. Click Client on the Enter menu
  4. Type the client’s last name, first name in the Client Selection window field
  5. Select Emergency Department from the New Encounter menu list

 

 

Question 25

Type: MCSA

The nurse has opened the New Encounter for a client in the Emergency Department. The appropriate next step is to:

  1. Enter the nursing diagnosis by locating the nursing tab
  2. Entering the vital signs by locating the Forms tab
  3. Enter the Chief complaint by locating the toolbar button labeled “Chief”
  4. Clicking on the Dx tab

 

Question 26

Type: MCSA

When documenting the client’s symptoms, the general rule regarding the “red” or “blue” buttons is:

  1. Red is used for lack of symptom
  2. Red is used for history of a symptom
  3. Blue is used for history of a symptom
  4. Blue is used for a current symptom

 

Question 27

Type: MCSA

The use of the note form is indicated

  1. If the nurse cannot find a diagnosis
  2. If the nurse cannot find a symptom
  3. If the nurse needs to expand on the detail of a selection
  4. If the computer system is not functioning well

 

Question 28

Type: MCSA

In order to document a 12-year history of dysmenorrhea, the nurse will:

  1. Select dysmenorrhea > Hx > Duration: 12 years > Prefix: History of
  2. Select dysmenorrhea > Note form: for 12 years
  3. Select dysmenorrhea
  4. Select Note form: History of dysmenorrhea for 12 years

 

Question 29

Type: MCMA

The student has been assigned to save an encounter to a PDF files. The appropriate actions include:

Standard Text: Select all that apply.

  1. Click the Print button from the Start menu
  2. Click the Print button on the Medcin toolbar
  3. Click to clear the check mark on “Current Encounter”
  4. Click on the button labeled “Export to XPS File”
  5. Click on the button labeled “Export to PDF File”

 

Question 30

Type: MCSA

The instructor has determined that the student work should be saved as a file that can be viewed with Adobe Acrobat Reader. On the Print dialog window, the student will select:

  1. Printer Setup
  2. Export to XPS File
  3. Export to PDF File
  4. Print and close

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 5

Question 1

Type: MCSA

Which of the following is not a characteristic of a Form?

  1. It typically lists all findings by category.
  2. It presents findings in the same place each time.
  3. It includes check boxes to speed data entry.
  4. It controls which findings are required and which are optional.

 

Question 2

Type: MCSA

Which of the following is not true of an EHR system when used in a medical clinic?

  1. It may take some time for healthcare providers to learn how to use the system.
  2. It makes the nurse’s interaction with the client less personal.
  3. It reduces the amount of paperwork to be done at the end of the day.
  4. When used correctly it ensures that the client’s chart is always up-to-date.

 

Question 3

Type: MCSA

Why are the Lists and Forms features in an EHR system useful to the nurse when seeing a client?

  1. Because they speed up the billing and reimbursement process
  2. Because they allow the client to independently select her symptoms
  3. Because they help a clinician quickly locate evidence to support a diagnosis
  4. Because they present the most frequently used findings in one place

 

Question 4

Type: MCSA

Which of the following is not true about a List in an EHR system?

  1. To work efficiently, lists are limited to a single condition.
  2. Lists are initially created manually by someone within a facility or practice.
  3. A short list will require the clinician to scroll through fewer findings than a longer list.
  4. Lists are typically created for the most commonly seen conditions.

 

Question 5

Type: MCSA

The nurse works in a pediatrician’s office that is implementing an EHR system. Which of the following conditions is least likely to warrant the creation of a List?

  1. Otitis media
  2. Influenza
  3. Degenerative joint disease
  4. Acne

 

Question 6

Type: MCSA

When using a specific list in the Student Edition software, what would you expect to see in the left pane of the Sx tab display?

  1. The full Medcin Nomenclature
  2. A past medical history for the client
  3. Symptoms related to the client’s chief complaint
  4. A form with symptoms listed by body system

 

Question 7

Type: MCSA

The attending physician has diagnosed a client with a hyperthyroidism. This nurse understands that this diagnosis relates to which of the following body systems?

  1. Cardiovascular
  2. Endocrine
  3. Gastrointestinal
  4. Genitourinary

 

Question 8

Type: MCSA

Mr. Talbot visits the clinic with a suspected sinus condition. Which of the following statements is true?

  1. The nurse will document the symptoms that correspond to his final diagnosis.
  2. The nurse will use the ROS to document symptoms directly related to the chief complaint.
  3. The nurse will interview Mr. Talbot and enter all of his symptoms in the HPI.
  4. The nurse will document symptoms related to Mr. Talbot’s present illness within the HPI.

 

Question 9

Type: MCSA

When using the Student Edition software, how do you know that the ROS groupings in “on”?

  1. The ROS button is blue.
  2. The ROS button is orange.
  3. The ROS button is gray.
  4. The ROS button does not change.

 

Question 10

Type: MCSA

When using the Student Edition software, where do the symptoms you select when the ROS button is activated appear on the printed encounter note?

  1. Review of systems
  2. Vital signs
  3. Assessment
  4. Allergies

 

Question 11

Type: MCSA

Which of the following is not true about the ROS button on the Toolbar?

  1. When the button is on, it applies to all the symptoms selected.
  2. It is available anytime you are on the Sx tab.
  3. It records symptoms on the Review of Systems portion of the encounter.
  4. When the button is on, it only affects a selected finding.

 

Question 12

Type: MCSA

On which of the following tabs will the Auto Negative button function?

  1. Sx and Dx
  2. Hx and Rx
  3. Px and Sx
  4. Tx and Rx

 

Question 13

Type: MCSA

You have selected the Auto Negative button to record a client’s symptoms. This feature will:

  1. automatically record all of the body system categories in the ROS as normal.
  2. record all previously unselected symptoms related to the client’s condition as normal.
  3. search the symptoms that have been selected by the nurse and make sure they match the HPI.
  4. record the symptoms the client has reported.

 

Question 14

Type: MCSA

When using a list for a specific condition in an EHR, the Rx tab is least likely to display which of the following?

  1. An experimental treatment
  2. A generic drug equivalent
  3. An over-the-counter drug
  4. A brand name drug

 

Question 15

Type: MCSA

A client indicates that he is currently taking no medications other than multivitamins. Where would this information be recorded on the printed encounter note?

  1. Physical findings
  2. Past medical/surgical history
  3. History of present illness
  4. Behavioral history

 

Question 16

Type: MCSA

Which of the following is not true about check boxes when they appear in a form within an EHR?

  1. All boxes that are checked will appear on the client’s record.
  2. Once a box has been checked, it is difficult to deselect.
  3. To record a finding, the user clicks on a box to create a check mark.
  4. A check placed within a N box indicates a client does not have something.

 

 

Question 17

Type: MCSA

Your client only reports a few symptoms during an examination. Which of the following would be the fastest way to complete Form pages for this client encounter?

  1. Place a check mark in all of the N boxes.
  2. Skip all options that do not apply to the client’s HPI.
  3. Use free text to type a note: Client is generally healthy, with few symptoms.
  4. Click on the “Negs” button in the Toolbar.

 

Question 18

Type: MCSA

The nurse is using a form to record information in the Student Edition software, but wants to make sure everything has been captured. The quickest option would be to:

  1. switch to the Encounter tab to verify all the information is correct.
  2. print the encounter note and proofread it before continuing.
  3. select Outline View to see all of the findings you have currently selected.
  4. choose Note View to see the encounter form in its current form.

 

Question 19

Type: MCSA

Which of the following statements is not true about the Auto Negative feature in the Student Edition software?

  1. It may be considered an “auto normal” feature.
  2. It saves providers time when they are using both Lists and forms.
  3. It automatically uses N when it populates check boxes.
  4. It does not automatically override the findings the user has already selected.

 

Question 20

Type: MCSA

A nurse records an inpatient’s admission diagnosis using which of the following?

  1. Sx tab and HPI button.
  2. Hx tab and ROS button.
  3. Dx tab and Prefix field.
  4. Px tab and Status field.

 

Question 21

Type: MCMA

The use of lists and forms at point of care documentation enables the nurse to:

Standard Text: Select all that apply.

  1. Record data quickly
  2. Clarify the any point of concern
  3. Wait until the end of the shift to chart
  4. Accurately document symptoms, history, etc.
  5. Make client data available to other caregivers immediately

 

Question 22

Type: MCMA

The acute care facility may create lists for which of the following reasons:

Standard Text: Select all that apply.

  1. Geographic location may cause a facility to see more cases of a particular nature than similar facilities in another region
  2. There may be seasonal increases of certain diseases
  3. The facility may focus on certain diseases
  4. The facility wants the caregivers to spend more time carefully documenting
  5. The physician may specialize in certain types of cases

 

Question 23

Type: MCMA

The Lists used in an EHR are created by:

Standard Text: Select all that apply.

  1. The CDC representatives
  2. Facility Clinical Information Services
  3. Nurses
  4. Unlicensed assistive personnel
  5. Clinicians

 

Question 24

Type: MCMA

The nurse understands that ROS typically incorporates the following:

Standard Text: Select all that apply.

  1. It organizes an exam by body systems starting from the heart to the genitourinary system
  2. It includes HEENT as one system
  3. Documentation of symptoms that directly relate to the Chief complaint
  4. Includes Emotions as a body system
  5. Includes breast findings within the integumentary system

 

Question 25

Type: MCSA

In many EHR systems, which of the following can be used to document normal findings quickly?

  1. Forms
  2. ROS
  3. Auto Negatives
  4. Lists

 

Question 26

Type: MCMA

The nurse is documenting the Px of a client whose chief complaint is an upper respiratory illness. The Auto Negative populated the negative finding for fever in the ROS. The nurse takes the client’s temperature and notes that there is a mild fever. The appropriate actions include:

Standard Text: Select all that apply.

  1. Click on the (red button) No fever
  2. Click on the (blue button) No fever
  3. Select mild from the prefix menu
  4. Select mild from the modifier menu
  5. Click on the HPI button next to the finding

 

Question 27

Type: MCSA

The nurse is recording the Sx and Px of a client with a chief complaint of dizziness. Using a list created for Syncope, the nurse understands that certain negative symptoms are:

  1. Populated using Auto Negative
  2. Are pertinent to the HPI
  3. Used to create a longer encounter note
  4. Used to modify findings

 

Question 28

Type: MCMA

Nurses use forms in order to:

Standard Text: Select all that apply.

  1. Speed data entry of positive and negative findings
  2. Enable Entry Details field data
  3. Group findings by a type of encounter
  4. Group findings using the appropriate tab
  5. Include fields required to meet regulatory requirements

 

Question 29

Type: MCSA

When the nurse is filling out a form, checking an empty box

  1. Removes a finding
  2. Adds a finding
  3. Moves the finding to the ROS
  4. Opens the form

 

Question 30

Type: MCMA

The nurse is entering an admission encounter on a client with a chief complaint consistent with an URI. Potential Forms and Lists that could speed documentation of the history and physical exam portions of the encounter include:

Standard Text: Select all that apply.

  1. Form for Surgical Intake
  2. Form for Short intake
  3. List for Respiratory Infections
  4. List for Adult URI symptoms
  5. Form for Respiratory Infections

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 6

Question 1

Type: MCMA

The nurse is reviewing a standardized care plan. This type of plan:

Standard Text: Select all that apply.

  1. Is defined for a specific medical condition
  2. Is used for the client with comorbidities
  3. May be incorporated into interdisciplinary plans
  4. Is often based on expert content documents
  5. May define a standard set of outcomes

 

Question 2

Type: MCSA

The individualized plan of care will be effective with

  1. groups of clients.
  2. one client.
  3. most of the clients with that same diagnosis.
  4. the physical therapy plan of care.

 

Question 3

Type: MCMA

The nurse works in a facility that uses an interactive plan of care. Advantages of this type of plan of care include:

Standard Text: Select all that apply.

  1. Individualization for a client’s specific needs
  2. It allows the nurse to choose nursing diagnoses, and outcomes
  3. Use of branching logic
  4. May be based on an individualized care plan
  5. Works based on intuitive nursing knowledge

 

Question 4

Type: MCMA

Nursing EHR applications have been traditionally developed with little or no input from nursing personnel. This changed due to the following major initiatives:

Standard Text: Select all that apply.

  1. Use of preprinted care plans
  2. Attention on CPOE
  3. Quality initiatives by JCAHO
  4. Quality initiatives by CMS
  5. Documentation of national client safety, core quality, and outcome measures

 

Question 5

Type: MCSA

The CCC system consists of two interrelated, classified terminologies, including

  1. Protocols
  2. Nursing Interventions and Actions
  3. Standardized nursing diagnosis
  4. Evidence based practice

 

Question 6

Type: MCSA

The nurse understands that the main advantage of the CCC System is the:

  1. Standardized approach to documenting client outcomes
  2. Codified approach to documenting the nursing care processes in an EHR
  3. The ability to modify the plan of care
  4. The ability to collect the client’s health data

 

Question 7

Type: MCMA

The nurse is using the CCC System framework for nursing documentation, which consists of:

Standard Text: Select all that apply.

  1. 27 Nursing Diagnoses
  2. 3 Actual Outcomes
  3. 198 Nursing Interventions
  4. 3 Expected Outcomes
  5. 14 Action Types

 

 

Question 8

Type: MCSA

The nurse understands the nursing process is a flow where the sixth step, evaluation leads to:

  1. Planning new care outcomes
  2. Determining new Nursing Diagnoses
  3. The first to reassess
  4. Implementation of new nursing interventions

 

Question 9

Type: MCSA

The CCC Documentation Step that corresponds with the Assessment step of the nursing process is

  1. Action Types
  2. Actual Outcomes
  3. Care Components
  4. Nursing Interventions

 

Question 10

Type: MCSA

Using the CCC System, the nurse finds that which step of the nursing process drives the selection of interventions?

  1. Assessment
  2. Diagnosis
  3. Planning
  4. Outcome Identification

 

Question 11

Type: MCSA

The initial step of the nursing process is

  1. Diagnosing
  2. Intervention identification
  3. Identification of outcomes
  4. Data collection

 

Question 12

Type: MCSA

The nurse analyzes the assessment data to determine

  1. Expected outcomes
  2. Prescribed interventions
  3. Attainment of outcomes
  4. Nursing diagnosis

 

 

Question 13

Type: MCSA

The nurse uses the plan of care to identify

  1. the nursing interventions appropriate for the client.
  2. the nursing diagnosis.
  3. expected outcomes.
  4. the client’s progress toward the attainment of outcomes.

 

Question 14

Type: MCSA

The six steps of the nursing process provide

  1. a basis for clinical decisions.
  2. nursing data for analysis.
  3. a list of Care Components.
  4. a codified approach to documentation.

 

Question 15

Type: MCSA

The nurse is preparing to Review the Plan of Care in the EHR. Which of the tabs in the Student Edition Software will allow the nurse to access this data?

  1. ADT
  2. Forms
  3. Options
  4. Select

 

Question 16

Type: MCMA

The nurse works in a facility that is transitioning from paper care pathways to an EHR with nursing plans of care. What are the similarities between the two?

Standard Text: Select all that apply.

  1. Both include Outcome Goals
  2. The nursing actions are individualized
  3. Both include clinical orders
  4. Both include nursing actions related to nursing diagnosis
  5. Both can address the needs of a client with comorbid diagnoses

 

 

Question 17

Type: MCMA

The nurse is using a CCC System to create an individualized plan of care. What is the benefit of using a CCC System?

Standard Text: Select all that apply.

  1. It follows the nursing process
  2. It allows the nurse to enter electronic nursing orders
  3. It follows a standard care plan
  4. The nursing diagnoses relate to medical diagnosis
  5. The quality of the plans may vary

 

Question 18

Type: MCSA

The nurse is preparing to create an individualized nursing plan of care. Which of the following steps is the initial action after choosing the client’s name?

  1. Locate and click the button labeled ADT
  2. Locate and click the button labeled Initial Data Entry
  3. Locate and click the button labeled Review Plan of Care
  4. Locate and click the tab labeled Encounter

 

Question 19

Type: MCSA

When creating an individualized plan, the nurse first reviews:

  1. The Outline view of the admission note
  2. Computer generated suggestions of nursing diagnoses
  3. The computer generated interventions
  4. The computer generated evaluation

 

Question 20

Type: MCMA

As the nurse reviews her assessment of a client, her actions in the EHR include:

Standard Text: Select all that apply.

  1. Click on the Px tab
  2. Click on the Hx tab
  3. Locate and click on the small minus sign next to a finding
  4. Locate and click on the small plus sign next to the finding
  5. Review entry

 

Question 21

Type: MCSA

The nurse is determining nursing diagnoses for a client with bacterial pneumonia. The appropriate tab for the nurse to select is

  1. Sx
  2. Px
  3. Tx
  4. Nurse

 

Question 22

Type: MCMA

When using the CCC System in the interactive nursing plan of care, the initial step (s) include (s) which of the following actions:

Standard Text: Select all that apply.

  1. Click on the ADT tab
  2. Click on the client’s name
  3. Click the Review Plan of Care
  4. Click Select on Menu bar
  5. Click on New Encounter

 

Question 23

Type: MCMA

Prior to entering data, the nurse is careful to:

Standard Text: Select all that apply.

  1. enter vital signs.
  2. select the date.
  3. review the client’s clinical orders.
  4. review the client’s nursing plan of care.
  5. enter test results.

 

Question 24

Type: MCSA

The nurse enters vital signs by clicking on the

  1. Sx tab
  2. Hx tab
  3. Px tab
  4. Rx tab

 

Question 25

Type: MCMA

When documenting nursing actions, such as the interventions for Activity care, the nurse would click the mouse on:

Standard Text: Select all that apply.

  1. assess activity level.
  2. findings.
  3. report complications of activity.
  4. resolve this diagnosis.
  5. wet nursing diagnosis to inactive.

 

Question 26

Type: MCSA

To document the resolution of a nursing diagnosis, the nurse will:

  1. type no longer required in the finding note.
  2. type care no longer required.
  3. right click on the nursing diagnosis.
  4. inactivate the nursing diagnosis.

 

 

Question 27

Type: MCSA

The nurse reviews the plan of care and notes that

  1. CCC outcomes parallel inactive nursing diagnoses.
  2. CCC outcomes parallel CCC goals, in the past tense.
  3. Nursing diagnoses mirror interventions.
  4. Nursing interventions mirror outcomes.

 

Question 28

Type: MCMA

The nurse reviews the plan of care and wishes to increase the frequency of a nursing intervention. The appropriate steps include:

Standard Text: Select all that apply.

  1. Right clicking on the intervention
  2. Click on Assess Actions
  3. Click on Teach Actions
  4. Click on Manage Actions
  5. Click on Change Sig

 

Question 29

Type: MCSA

The nurse determines the need to modify a plan of care that was initiated by a previous nurse. The appropriate action includes

  1. Clicking on ADT
  2. Click on Expected Outcome
  3. Click on Add a Goal for this Diagnosis
  4. Right click on Current and Active Diagnoses

 

Question 30

Type: MCSA

After the nurse adds a new Nursing Diagnosis to the plan of care, the next step is to

  1. Identify an Expected Outcome
  2. Identify an Intervention
  3. Identify a nursing action
  4. Identify the Goal

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 7

Question 1

Type: MCSA

The nurse explains that the abbreviation CPOE stands for:

  1. Computerized patient order exchange
  2. Computerized patient outcome evidence
  3. Computerized provider order entry
  4. Computerized prescription order entry

 

Question 2

Type: MCSA

CPOE systems will help do all of the following to improve workflow processes except:

  1. Prevent lost orders
  2. Identify duplicate orders
  3. Improve provider productivity
  4. Eliminate medication shortages

 

Question 3

Type: MCSA

A CPOE system would typically not be used by which of the following healthcare professionals?

  1. Physician
  2. Register dietician
  3. Medical coder
  4. Respiratory therapist

 

Question 4

Type: MCSA

No U.S. state currently allows which of the following healthcare professionals to write prescriptions for clients?

  1. Physician assistant
  2. Medical assistant
  3. Obstetrician
  4. Nurse practitioner

 

Question 5

Type: MCSA

Which of the following is not an example of a laboratory service?

  1. Cytology
  2. Chemistry
  3. Radiology
  4. Blood bank

 

Question 6

Type: MCSA

The subcategory of clinical pathology would include which of the following?

  1. Autopsy
  2. Urinalysis
  3. Biopsy
  4. Genetic testing

 

Question 7

Type: MCSA

Moira Gleason needs to have a CBC as part of her annual physical; this means Moira will most likely:

  1. have her blood drawn in the emergency department of her local hospital.
  2. have her blood drawn by a handheld device that then transfers test results to an EHR system.
  3. need to schedule another appointment at her provider’s office to have blood work done.
  4. have her blood drawn by a nurse or phlebotomist.

 

Question 8

Type: MCSA

Which of the following statements is not true about laboratory tests?

  1. In some cases a client will obtain his own specimen and bring it to a medical facility himself.
  2. Providers often need the results of a laboratory test before they can develop a treatment plan for a client.
  3. A CPOE system is only able to track lab orders once the client has had the test performed.
  4. Values within lab test report results are compared against normal reference ranges to show if a client is outside that range.

 

 

Question 9

Type: MCSA

Which of the following would not be considered a benefit of electronic lab orders?

  1. The provider may create a graph of test results over time.
  2. The client usually learns about her test results within 36 hours or less.
  3. Test results are stored in the EHR system.
  4. The provider may order an unlimited number of tests for a client.

Question 10

Type: MCSA

A nurse practitioner determines that her client needs blood work done. Which of the following is not a “task” within a CPOE system?

  1. Completing the requisition and obtaining a specimen
  2. Obtaining a specimen and sending it to a lab
  3. Ordering a lab test at the point-of-care
  4. Picking up the sample and transporting it to a lab

 

Question 11

Type: MCSA

The Search feature in the Student Edition software:

  1. finds every example of a word that is being searched.
  2. searches for words within a current tab only.
  3. requires the user to activate “automatic word completion” for that feature to work.
  4. finds and shows the highest-level match for the word that is being searched.

 

Question 12

Type: MCSA

Where will you find the Search feature in the Student Edition software?

  1. The Medcin Nomenclature Pane
  2. The Toolbar
  3. The Entry Details field
  4. The Menu Bar

 

Question 13

Type: MCSA

The best way to ensure that you will find a word quickly using the Search feature is to:

  1. spell the word correctly.
  2. search from within the correct tab.
  3. use plurals when needed.
  4. set the List Size to 1.

 

Question 14

Type: MCSA

The nurse practitioner orders a lipids panel test using the Entry Details Prefix field. This means

  1. that particular test has been performed by the clinic.
  2. the medical assistant has completed the lab requisition form.
  3. the lipids panel test is added to the Plan section of the encounter note.
  4. the lipids panel test becomes part of the Physical findings.

 

 

Question 15

Type: MCSA

John Brown arrives at a rheumatology clinic with a diagnosis of “possible rheumatoid arthritis.” What does this mean?

  1. Mr. Brown has been referred to a rheumatologist for an appointment.
  2. Mr. Brown’s physician needs more information before confirming the diagnosis.
  3. Mr. Brown has most of the symptoms of this condition, but not all of them.
  4. Mr. Brown’s insurance plan will not pay for this visit.

 

Question 16

Type: MCSA

A hospital inpatient needs an x-ray of her lung. The nurse understands that this order will originate from:

  1. CPOE
  2. PACS
  3. RIS
  4. CDR

 

Question 17

Type: MCSA

Which of the following types of diagnostic images uses the injection of a radioactive substance called a tracer as part of the imaging process?

  1. x-ray
  2. CAT
  3. MRI
  4. PET

 

Question 18

Type: MCSA

Why are radiology reports rarely available as a codified EHR record?

  1. Because this specialty has been slower than other specialties to implement EHR systems
  2. Because radiology reports are transmitted via DICOM
  3. Because most radiology reports are still dictated
  4. Because as part of the HIPAA Privacy Rule, radiology offices are not permitted to send electronic files to other providers

 

Question 19

Type: MCSA

A component of a pharmacy computer system that checks for potential medication dosing errors is known as:

  1. DAW
  2. DICOM
  3. Dx
  4. DUR

 

Question 20

Type: MCSA

The nurse understands that the EHR system in the hospital protects the client by closing the loop on medication administration. Which of the following statements about a hospital’s closed loop of medication administration is correct?

  1. It may be applied to both a paper-based and CPOE system.
  2. It is completely automated.
  3. It helps support the “10 Rights” of medication administration.
  4. Its use requires the client’s prior consent.

 

Question 21

Type: MCMA

The nurse understands that there are ‘10 rights’ for safe medication administration. These rights include:

Standard Text: Select all that apply.

  1. The right route of administration
  2. The right to omit a medication
  3. The right assessment
  4. The right nurse
  5. The right client education

 

Question 22

Type: MCMA

The physician has given the nurse a telephone order for pain medication for a client in the hospital. The nurse performs the following actions in the EHR:

Standard Text: Select all that apply.

  1. Clicks on Encounter to review the plan of care
  2. Document nursing assessment of pain level
  3. Search for medication ordered in the Dx tab
  4. Clicks on Plan of care to review clinical orders
  5. Review prescription information for accuracy

 

Question 23

Type: MCSA

The nurse enters a medication that was verbally ordered by the provider. After clicking Save Rx, the nurse realizes that the order was entered incorrectly. The correct action is to

  1. delete the order.
  2. use the Rx Inquiry function.
  3. re-enter the order.
  4. ask the provider to change the order.

 

Question 24

Type: MCMA

ICD-9-CM and ICD-10 codes are used for:

Standard Text: Select all that apply.

  1. Statistical studies of causes of death
  2. Billing specific client services
  3. Standardized coding of diseases
  4. Statistical studies of injury
  5. Creating problem lists and treatment plans

 

Question 25

Type: MCSA

The provider is caring for a client who complains of chest pain intermittently. In the Encounter view, the provider would click which button to access a list of orders by diagnosis?

  1. Search
  2. List size
  3. List
  4. Chief

 

Question 26

Type: MCSA

After the nurse practitioner selects a list of Orders by Dx, which tab should automatically be displayed?

  1. Dx
  2. Sx
  3. Px
  4. Tx

 

Question 27

Type: MCMA

The nurse uses a diagnosis protocol to:

Standard Text: Select all that apply.

  1. document the exam and write orders quickly.
  2. generate specific sets of tests that are used to monitor a particular disease.
  3. generate a list of nursing interventions appropriate for a nursing diagnosis.
  4. search for medications.
  5. enter multiple tests.

 

Question 28

Type: MCMA

A quick-pick list is used by health care professionals to:

Standard Text: Select all that apply.

  1. display a diagnosis based order set.
  2. display a list of frequently seen clients.
  3. display a list of frequently ordered medications.
  4. display a list of frequently ordered tests.
  5. display a list of frequently seen vital signs.

 

Question 29

Type: MCMA

A quick-pick list to order medications is accessed by the nurse by:

Standard Text: Select all that apply.

  1. clicking on the Tx tab.
  2. clicking on the Rx tab.
  3. clicking on the List button.
  4. completing the Entry details portion of the screen.
  5. completing the Rx Writer.

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 8

Question 1

Type: MCSA

Which of the following is least likely to require or use a longitudinal medical record?

  1. Physician’s office
  2. Acute care hospital
  3. Dialysis center
  4. Chiropractor’s office

 

Question 2

Type: MCSA

What is a Problem List?

  1. A compilation of all symptoms a client describes in the interview
  2. A list of primary diagnoses used for billing purposes
  3. An up-to-date list of a client’s diagnoses and conditions
  4. A drop-down menu that allows the provider to select findings quickly

 

Question 3

Type: MCSA

Which of the following would not appear on a Problem List?

  1. Onset date
  2. Mammogram recommendations
  3. Problem status
  4. Vital signs data

 

Question 4

Type: MCSA

Why would a primary care nurse practitioner choose to add a problem to a client’s Problem List automatically?

  1. When the nurse wants to ensure that all possible conditions appear on the list for future reference
  2. When the nurse is trying to rule out different diagnoses
  3. When the nurse wants to document problems that are being treated by a specialist elsewhere
  4. When the nurse has already confirmed a diagnosis for the client

 

Question 5

Type: MCSA

Certain wellness conditions may be included as part of the Problem List based on which of the following client information?

  1. Family history
  2. Gender
  3. Chronic conditions
  4. Client preference

 

Question 6

Type: MCSA

The nurse is creating a new encounter for Mrs. Shelly, a longtime client at the medical clinic. When creating the new encounter note for this client, how should the nurse compare information from Mrs. Shelly’s previous encounters?

  1. By loading the Problem List
  2. By using the Search feature
  3. By clicking on the Manage tab
  4. By using the Care Plan tab

 

Question 7

Type: MCSA

On what tab does the Patient Management feature automatically open?

  1. Problems
  2. Care Plan
  3. Past Medical/Surgical History
  4. Medications

 

Question 8

Type: MCSA

A client indicates she is using an herbal supplement to ease her menopausal symptoms. The nurse will find this information within which Patient Management section of the Student Edition software?

  1. Problems
  2. Care Plan
  3. Medications
  4. Allergies

 

Question 9

Type: MCSA

Which of the following statements about the Patient Management section of the Student Edition software is not correct?

  1. The Medications tab displays medication information that has been ordered by the client’s primary care provider and no one else.
  2. Information about a client’s vaccines is displayed in both the Medications tab and the Vaccines tab.
  3. It is possible to add additional findings to the Care Plan tab, but this must be done manually.
  4. Clicking on the Details button allows the user to view more of the Patient Management screen.

 

Question 10

Type: MCSA

Where does the data that appears in the Med/Surg tab of the Patient Management section come from?

  1. Family History
  2. Problem List
  3. Chief Complaint
  4. Past History

 

Question 11

Type: MCSA

The nurse understands that all of the following statements about the tabs in Patient Management are accurate except?

  1. To sort data within the Vitals tab, click on the Sort button.
  2. It is possible to sort any tab of Patient Management.
  3. After sorting data within the Vitals tab, click on the date column.
  4. When sorting data within a column, the entire row stays together.

 

Question 12

Type: MCSA

When using Patient Management, how would a clinician indicate that the treatment plan for a specific client problem was working?

  1. The clinician would select “well controlled” from the Problem List tab drop-down list to record the status.
  2. The clinician would select Clear This Problem from the Problem List tab drop-down list because it is no longer a problem.
  3. The clinician would select Order a Test from the Problem List tab drop-down list to verify the treatment was working.
  4. The clinician would select Order a Therapy to make sure the client has the refills he needs.

 

Question 13

Type: MCSA

What does choosing “resolved” for a particular problem do automatically?

  1. It cancels all previous orders related to that problem.
  2. It discontinues all medication orders related to that problem.
  3. It moves the problem to the client’s history.
  4. It sets appropriate default actions related to that problem.

 

Question 14

Type: MCSA

A nurse practitioner sees a client who is normally seen by a physician within a medical office. The client says she had a series of tests done earlier in the week, but hasn’t heard anything yet. The nurse practitioner would:

  1. choose Entry Details to find out specific information on the types of tests that were ordered.
  2. send an e-mail to the laboratory where the client had her tests done to see if the results are back yet.
  3. click on Pending Orders in Patient Management to find out the status of the client’s tests.
  4. use the Search feature to check on any recent lab test requisitions that may have been made for the client.

 

Question 15

Type: MCSA

The process of comparing information, such as test results, over a period of time is called:

  1. Tracking
  2. Graphing
  3. Trending
  4. Charting

 

Question 16

Type: MCSA

A graph showing an individual client’s weight fluctuations over time would be least helpful when performing which of the following tasks?

  1. Educating the client about his diet
  2. Developing a care plan for the client
  3. Determining if the client has a genetic predisposition to obesity
  4. Tracking the success of an ongoing exercise regimen

 

Question 17

Type: MCSA

All of the following are available as options on the Graph menu except:

  1. Weight
  2. Body Mass Index
  3. Current Finding
  4. Blood pressure

 

Question 18

Type: MCSA

The nurse is preparing to label a problem. Which of the following problems would be considered “Acute Self-Limiting”?

  1. Breast cancer
  2. COPD
  3. Allergies
  4. Rhinitis

 

Question 19

Type: MCSA

The nurse is reviewing a client’s discharge medication orders. Before giving the client a new prescription, she or he should always check:

  1. Medications and vaccines
  2. Allergies and medications
  3. Past Medical/Surgical History
  4. Social History

 

Question 20

Type: MCSA

The nurse is reviewing the client’s EHR and notes a lab order is marked “preliminary;” this means that the:

  1. order has been sent, but no results are available yet.
  2. results show an early indication of the test, but they are not verified.
  3. test results have been verified and are ready for the clinician.
  4. test has been repeated because results are inconclusive.

 

 

Question 21

Type: MCSA

The nurse is reviewing an obstetric client’s EHR prior to the office visit. The quickest way for the nurse to review the previous encounters is to:

  1. click on Search
  2. click on Encounter Details
  3. click on Manage
  4. click on details

 

Question 22

Type: MCSA

The nurse is preparing to assess a client who is returning for a follow-up visit after a sinus infection. After clicking on the Manage tab, the nurse clicks the Problem List. An appropriate next action would be to:

  1. select order a test.
  2. select order a medication.
  3. select Nursing to enter the nursing diagnosis
  4. select Quick H&P

 

Question 23

Type: MCSA

The client reports that the sinus infection has resolved. The nurse clicks on resolved from the menu available. The following action will occur:

  1. the problem will be deleted.
  2. the problem will remain in the Active Problems list until manually removed.
  3. the previous orders will automatically be cancelled.
  4. the nurse will then document in the current encounter that the previous orders. can be canceled

 

Question 24

Type: MCMA

The nurse is reviewing a client’s lab results. In order to see the tests that have been ordered, the nurse:

Standard Text: Select all that apply.

  1. clicks Manage.
  2. clicks Tx .
  3. clicks Problem list.
  4. clicks Select on the Menu bar.
  5. clicks existing encounter.

 

Question 25

Type: MCSA

In order to review the blood work results of a client, the nurse will open the

  1. Problem List.
  2. Care Plan.
  3. Chief.
  4. History.

 

Question 26

Type: MCSA

The nurse will quickly know which tests have results entered in the EHR by

  1. The test names that are flashing have results in the system
  2. The test names that are highlighted in red have abnormal results in the system
  3. The test results that are highlighted in yellow have results in the system
  4. The test names that are in bold indicate those that have results in the system

 

Question 27

Type: MCSA

In order to see the results of ordered Tests, the nurse will

  1. right click on the bold typed test name.
  2. right click in the column heading.
  3. left click on Nursing assessment.
  4. select ROS.

 

Question 28

Type: MCSA

The nurse is caring for a client who has been bleeding from a duodenal ulcer, and has received several blood transfusions. The provider has been ordering a daily CBC to follow the client’s progress. The nurse will select CBC and then:

  1. select enter from the tool bar.
  2. select Options from the tool bar.
  3. select graph from the tool bar.
  4. select Tx from the tool bar.

 

Question 29

Type: MCSA

The client is caring for a client with chronic hypertension. After the physician visit and prior to a teaching session, the nurse prepares a graph of the client’s previous blood pressure measurements. In order to locate the results, the nurse will first

  1. select the client’s blood pressure from the encounter.
  2. select the client’s vital signs after clicking History.
  3. select Hx from the Encounter view.
  4. select Px from the Encounter view.

 

Question 30

Type: MCMA

The client requests a graph of her weight measurements. The nurse is able to provide this most quickly by:

Standard Text: Select all that apply.

  1. clicking on Graph from the tool bar.
  2. clicking on weight in the current encounter.
  3. clicking on the problem list from the Manage view.
  4. clicking on weight from the encounter and then Select.
  5. clicking on Weight from the drop down menu.

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 9

Question 1

Type: MCSA

What is a flow sheet?

  1. A feature of the software that displays a desired group of findings in a presentation that allows for quick entry of not only the selected findings, but of any entry details as well.
  2. A feature of the software that presents data from multiple encounters in column format that resembles a spreadsheet.
  3. A feature of the software that provides a list of the medications that the client currently is taking.
  4. A feature of the software that displays all of the standard plans of therapy used to treat common diseases or conditions.

 

Question 2

Type: MCSA

Which of the following does the nurse consider an advantage of a flow sheet?

  1. It allows findings from any previous encounter to be cited into the current note.
  2. It allows the provider to enter selected findings quickly.
  3. It allows a nurse to link an annotated drawing to a relevant finding.
  4. It simplifies information about combinations of multiple diseases.

 

Question 3

Type: MCSA

Which of the following statements about flow sheet is correct?

  1. Flow sheets typically display data from the current encounter only.
  2. Flow sheets are generally limited to lab results or vital signs.
  3. Single flow sheets are generally less useful for clients who have a chronic disease.
  4. EHR systems will vary on how they implement flow sheets.

 

Question 4

Type: MCSA

Jared Peters has type 2 diabetes, hypertension, and a new diagnosis of macular degeneration. When the nurse sees Jared during an encounter, which of the following is the most likely scenario?

  1. The nurse will use one flow sheet for Jared that includes all of his current chronic diseases.
  2. The nurse will use separate flow sheets for each of Jared’s chronic conditions, but will need to enter the same findings more than once.
  3. The nurse will use flow sheets for Jared’s diabetes, but not for his other chronic conditions.
  4. The macular degeneration flow sheet will not have columns for previous encounters.

 

Question 5

Type: MCSA

The nurse has invoked a flow sheet using the Student Edition software from a form; what does this mean?

  1. The first column of the flow sheet is populated by findings pertinent to the selected Form.
  2. The findings that appear in the first column of the flow sheet display the dates of the client’s previous visits.
  3. The Ellipsis button, which opens the Data Details window, is disabled.
  4. The flow sheet displays all findings in the current encounter.

 

Question 6

Type: MCSA

The nurse is viewing a flow sheet for a client and wishes to see details from a previous encounter. How does she do this?

  1. By clicking on the date of the previous encounter
  2. By clicking on the Details button
  3. By clicking anywhere in the column beneath a date
  4. By clicking on the Narrative window button

 

Question 7

Type: MCSA

What does the Cite feature do?

  1. It provides a view of the plan from each previous encounter in a problem-oriented view.
  2. It brings forward findings from a previous encounter into the current encounter.
  3. It reminds the nurse about certain actions that must be taken.
  4. It generates a list of findings that are clinically related to the finding currently highlighted.

 

Question 8

Type: MCSA

When the nurse is working with a flow sheet, how do he know that the Cite button is on?

  1. The Cite button will disappear.
  2. The mouse pointer will change to a large question mark.
  3. The Ellipsis button turns orange.
  4. The mouse pointer changes into a teal check mark.

 

Question 9

Type: MCSA

A client has had a new cholesterol test result, and the nurse is using the Cite window to record this finding. The nurse should remember that:

  1. the data you enter will post to the current client encounter.
  2. you need to use the Clear button first before entering new findings.
  3. unless you are careful, you may inadvertently change a previous encounter.
  4. to cite an individual finding, you need to use the cite review window.

 

Question 10

Type: MCSA

The nurse needs to review the narrative of a previous encounter while viewing a flow sheet of a client’s hypertension findings. In which of the following positions should the buttons be in if you wish to view the narrative of an encounter from within a flow sheet?

  1. FS Flow Off
  2. Cite Off
  3. Cite On
  4. ROS On

 

Question 11

Type: MCSA

A pediatric clinic would be least likely to use a flow sheet for which of the following?

  1. Diabetes
  2. Vitals
  3. Pregnancy
  4. Otitis media

 

Question 12

Type: MCSA

Which of the following is true about a form-based flow sheet?

  1. It displays all of the details from previous encounters.
  2. It displays new findings that may be related to the client’s condition.
  3. It displays all of the findings that match a Problem List.
  4. It displays all of the findings that match the form.

 

Question 13

Type: MCSA

The nurse wants to create a flow sheet that is based on a specific problem. To accomplish this task, what do the nurse need to do first?

  1. Click on the Problem List tab.
  2. Click on the Details button.
  3. Click on the Manage tab.
  4. Click on the Flow sheet button.

 

 

Question 14

Type: MCSA

A problem-oriented flow sheet would <i>not</i> include which of the following?

  1. All findings that are related to a specific problem
  2. Findings from previous client encounters
  3. Findings that related to individual body systems
  4. Findings that are related to the client’s other problems

 

Question 15

Type: MCSA

On which of the following devices is an anatomical drawing the easiest to utilize and navigate?

  1. Laptop computer
  2. Tablet PC
  3. Computer workstation
  4. Cellular phone

 

Question 16

Type: MCSA

Why would an EHR system that allows a nurse to select findings related to a sprained ankle by viewing an anatomic illustration of the foot be useful?

  1. Because the EHR system adds both the findings and the illustration to the encounter note
  2. Because it allows the nurse to zero in on the appropriate findings quickly
  3. Because it allows both the nurse and the client to communicate more effectively about a problem
  4. Because the illustration of the ankle may be printed at the end of the encounter for client education materials

 

Question 17

Type: MCSA

The nurse in which of the following medical specialty clinics would be least likely to include annotated drawings as part of encounter notes?

  1. Dermatology
  2. Cardiology
  3. Behavioral
  4. Ophthalmology

 

Question 18

Type: MCSA

What happens to a handwritten note that a nurse adds to an annotated anatomical drawing?

  1. The note becomes codified data.
  2. The note is not saved by the EHR.
  3. The note is not searchable by the EHR.
  4. The note may then be used to locate the image later.

 

Question 19

Type: MCSA

The nursing student is selecting an anatomical drawing for annotation within the Student Edition software. This means the student may need to select all of the following except:

  1. The body system they wish to show
  2. The gender of the image
  3. The view of the image
  4. The region they wish to show

 

Question 20

Type: MCSA

The Line drawing tool would be most useful to accomplish which of the following when annotating a drawing within the EHR?

  1. To emphasize a body region
  2. To make a box on the drawing
  3. To connect elements on the drawing
  4. To create a free-hand drawing

 

Question 21

Type: MCMA

The nurse who works in a cardiovascular clinic is likely to use a flow sheet to monitor

Standard Text: Select all that apply.

  1. Weight
  2. Height
  3. Edema
  4. Pulse
  5. Blood pressure

 

Question 22

Type: MCSA

The nurse in the pediatric endocrinology clinic uses a form to enter the routine follow-up visit information. In order to see this information in flow sheet format, the nurse needs to:

  1. Search for Flow Sheets
  2. Click Select on the tool bar
  3. Click Lists on the tool bar
  4. Click FS Form on the tool bar

 

Question 23

Type: MCSA

The nurse notes that the current blood pressure reading is significantly lower than on a previous encounter. In order to quickly see the details of that previous encounter, the nurse will:

  1. Click the date at the top of the column
  2. Click on the Ellipsis button next to the blood pressure finding
  3. Click on Select and choose previous encounter
  4. Select search and enter the date

 

Question 24

Type: MCSA

The nurse in the long-term care facility is reviewing the client’s problem list. In order to view the client’s progress towards weight gain, the most efficient choice is to:

  1. Click Manage > Highlight the Undernutrition problem > List
  2. Click Manage > highlight the Undernutrition problem > Details
  3. Click Manage > highlight the Undernutrition problem > Flow sheet
  4. Click Manage > highlight the Undernutrition problem > Select

 

Question 25

Type: MCSA

The nurse is reviewing the inpatient’s plan of care. The flow sheet format for Nursing Diagnoses is different than the Problem based flow sheet in the following ways:

  1. The Plan of care flow sheet has no columns with dates
  2. Nursing Diagnosis flow sheet includes all nursing diagnoses
  3. The Nursing Diagnosis flow sheet allow the nurse to view the narrative note by clicking on the date
  4. The Problem based flow sheet displays all active problems
  5. The Nursing Diagnosis flow sheet does not allow for use of the Cite feature

 

Question 26

Type: MCSA

When using the Cite feature in a Nursing Diagnosis flow sheet, the nurse uses which button to add free text to an entry?

  1. The nurse cannot enter free text in this view
  2. The nurse will use the Details button
  3. The nurse will click on Encounter
  4. The nurse will click on Select

 

Question 27

Type: MCSA

The nurse is able to document using the Plan of Care flow sheet by using the:

  1. Grid button
  2. ROS button
  3. Cite button
  4. Forms button

 

Question 28

Type: MCSA

The nurse is explaining a flow sheet to a client. An accurate comparison would be:

  1. it is similar to a word processing document.
  2. it is similar to a list document.
  3. it is similar to a picture.
  4. it is similar to a spreadsheet.

 

Question 29

Type: MCMA

The nurse is reviewing the client’s plan of care. The methods of recording data in the flow sheet view of the care plan include:

Standard Text: Select all that apply.

  1. Using the Search button
  2. Using the Cite feature
  3. Using the Red and Blue buttons in the flow sheet
  4. Using the Prompt feature
  5. Using the Graph feature

 

Question 30

Type: MCMA

The Student Edition software allows creation of flow sheets based on:

Standard Text: Select all that apply.

  1. Lists
  2. Problems
  3. Forms
  4. Nursing plan of care
  5. ROS

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 10

Question 1

Type: MCMA

The nurse is preparing the client for discharge from the acute care facility. Potential LTC facilities for this client include:

Standard Text: Select all that apply.

  1. A SNF
  2. LTAC
  3. Hospice
  4. Home
  5. Residential care facility

 

Question 2

Type: MCSA

The average length of stay in the acute care hospital is

  1. 30 days
  2. 2 days
  3. Less than 30 days
  4. More than 30 days

 

Question 3

Type: MCSA

The nurse is caring for a client who is preparing for discharge. The client lives alone, and has a complicated wound dressing that needs to be changed daily, as well as needing assistance with many ADLs at this time. The appropriate discharge arrangement for this client would be:

  1. A rehabilitation facility
  2. A residential care facility
  3. Hospice
  4. Home

 

Question 4

Type: MCSA

Services that a nurse may provide the client in the rehabilitation facility include

  1. Visiting the Client’s home
  2. Holistic support during the dying process
  3. Providing care only when requested
  4. Counseling

 

Question 5

Type: MCMA

Services that are available in the home setting may include:

Standard Text: Select all that apply.

  1. Dressing changes
  2. Assistance with ADLs
  3. Physical therapy
  4. Range of Motion
  5. Acute care

 

Question 6

Type: MCSA

The nurse is discussing the discharge plan for a client with the interdisciplinary team. The client lives alone, and will require long-term intravenous therapy, and mechanical ventilation for a period of time. The appropriate placement for this client would be:

  1. A residential care facility
  2. Home
  3. Hospice
  4. SNF

 

Question 7

Type: MCMA

The nurse is evaluating two job opportunities, one in home care and one in a SNF. Similarities in the two care settings include:

Standard Text: Select all that apply.

  1. Assessments are required in a timely manner
  2. There are government-mandated forms for both settings
  3. ADLs are assessed in only the SNF setting
  4. Funding may be dependent on charting
  5. Billing may be done prior to assessments being completed

 

Question 8

Type: MCMA

The charge nurse is providing orientation to a group of new nurses in a SNF. Regulations that are important to explain to the new employees include:

Standard Text: Select all that apply.

  1. Any possible violation of a resident’s rights must be verbally investigated
  2. The MDS 3.0 must be use to assess the resident’s needs and desires
  3. The MDS 3.0 may be completed by the nurse
  4. CMS requires updated assessment at specific and situational intervals
  5. Medical records only need to be reviewed by the staff on the unit

 

Question 9

Type: MCSA

The skilled nursing home is the appropriate setting for which of the following clients:

  1. A client who is able to get around but requires some assistance with bathing
  2. A client who is detoxifying from prescription medication
  3. A client who requires complicated dressing changes and physical therapy
  4. A client who has become forgetful and gets confused at night

 

 

Question 10

Type: MCSA

The nurse is explaining that the care of client’s in a nursing home involves many elements of regulations, including:

  1. Calling the patients in nursing homes patients
  2. Handing each client a list of rights and responsibilities to read
  3. Treating the client as family, and using ‘honey’ or ‘sweetie’ to address the client
  4. Calling the patients in nursing homes residents

 

Question 11

Type: MCMA

The nurse is caring for a client who is returning to the nursing home after being admitted to the hospital for chest pain. Appropriate actions include:

Standard Text: Select all that apply.

  1. Writing a short note in the client’s chart that includes the date and time of re-admission
  2. Updating the resident’s assessment information
  3. Thoroughly documenting the transfer
  4. Reviewing the residents assessment information
  5. Identify the changes in the comprehensive care plan

 

Question 12

Type: MCSA

The RAI is used to collect information to use with

  1. Standardized care plans
  2. Individualized care plans
  3. Discharge planning
  4. Staff education

 

Question 13

Type: MCSA

The RAI is usually completed by

  1. The resident
  2. The nurse
  3. The interdisciplinary team
  4. The resident’s family

 

Question 14

Type: MCMA

The RAI consists of:

Standard Text: Select all that apply.

  1. A set of screening elements
  2. A care area assessment process
  3. Identification of residents who are at risk for developing specific functional problems and require further assessment
  4. Intuitive nursing judgments
  5. The MDS 3.0

 

 

Question 15

Type: MCSA

The RAI is a

  1. 4 page assessment form
  2. 38 page form
  3. Tool used only by nursing staff
  4. Tool used for billing purposes

 

Question 16

Type: MCMA

The nurse is beginning to fill out the RAI on a newly admitted client. Information that is required includes:

Standard Text: Select all that apply.

  1. Type of provider
  2. Resident race and ethnicity information
  3. Resident sexual orientation
  4. Resident medical record number
  5. Date of MDS 3.0 assessment

 

Question 17

Type: MCSA

Which of the following statements about MDS 3.0 is true?

  1. It is performed on a monthly basis
  2. It is performed by the resident
  3. Entries need to be verified as the process progresses
  4. It is only required for clients over 65

 

Question 18

Type: MCSA

The MDS 3.0 assessment tool includes all of the following

  1. The client’s preferences
  2. A functional status assessment
  3. A list of active diagnoses
  4. A list of family members
  5. A mood interview

 

Question 19

Type: MCSA

The nurse is coding the resident’s ADL self-performance. The

  1. The most independent level
  2. The most dependent level
  3. The Support Provided code
  4. The activities that do not occur at all

 

Question 20

Type: MCMA

Home health care involves which type of healthcare providers?

Standard Text: Select all that apply.

  1. Nurses
  2. Businesses
  3. Restaurants
  4. Paraprofessionals
  5. Children

 

Question 21

Type: MCMA

Characteristics of the home setting include:

Standard Text: Select all that apply.

  1. There are rules governing visitors and pets
  2. Support staff is available around the clock
  3. The health care team has little control over the healing environment
  4. Family members are often the ones who implement the care plan
  5. The care plan’s outcome is within the nurse’s control

 

 

Question 22

Type: MCMA

Clients may be referred to home health providers by:

Standard Text: Select all that apply.

  1. Physicians
  2. Nurses
  3. Therapists
  4. Family members
  5. A neighbor

 

Question 23

Type: MCMA

Home health nursing requires the nurse to consider which of the following:

Standard Text: Select all that apply.

  1. Coordination of care
  2. Client education
  3. The nurse is required to provide the majority of the care
  4. Assisting the client with problem solving
  5. Unlimited time with each client

 

Question 24

Type: MCSA

The majority of the clients a home care nurse provides care for are

  1. Children
  2. Adults
  3. Elderly
  4. From nursing homes

 

Question 25

Type: MCSA

Which of the following is true about home care?

  1. Most clients pay independently
  2. Most clients have Medicaid
  3. Documentation is critical to reimbursement
  4. The MDS 3.0 is used to assess the client’s functional status and environment

 

Question 26

Type: MCMA

OASIS-C is a group of data elements that:

Standard Text: Select all that apply.

  1. Was developed by Blue Cross
  2. Represents core items of a comprehensive assessment for an adult home care client
  3. Is the basis for measuring client goals
  4. Uses evidence-based tools
  5. Includes several risk assessment measurements

 

Question 27

Type: MCMA

The OASIS-C data is gathered:

Standard Text: Select all that apply.

  1. At the start of care
  2. When care is terminated
  3. When requested by client
  4. monthly
  5. When transferred to an inpatient facility

 

Question 28

Type: MCSA

The nurse is completing a partial OASIS-C data collection on a client. The tabs identified as ADL/IADL, ADL/IADL 2, and ADL/IADL 3-4 are used

  1. Depending on the client’s level of mobility
  2. Depending on the client’s ability to meet ADLs independently
  3. To provided detailed information about a variety of activities
  4. To identify client outcomes

 

Question 29

Type: MCSA

The nurse is reviewing a client’s nursing plan of care from the acute care facility. The nurse notes the following similarities or differences in the plan of care synopsis in the OASIS-C tool:

  1. The OASIS-C is extremely detailed
  2. The acute facility plan of care includes interventions from physical therapy occupational therapy, and speech pathology
  3. The acute facility plan includes risk assessments
  4. The OASIS-C is grouped by nursing diagnosis

 

Question 30

Type: MCSA

Which of the following statements is true about the OASIS?

  1. It is used to determine if the client requires care
  2. OASIS summarizes the agencies plan of care
  3. The nursing plan of care is included in the OASIS synopsis
  4. The OASIS is performed at prescribed intervals

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 11

Question 1

Type: MCSA

The ________ may be compared to the first automobiles because in the early stages of new technology people tend to look at things in the old way.

  1. Teleradiology
  2. Electronic health record
  3. iPod
  4. Electric car

 

Question 2

Type: MCSA

A client who arrives for an annual physical has brought along some information on healthy cholesterol levels he obtained from the Internet. How should the nurse handle this situation?

  1. Explain that the Internet contains a lot of inaccurate information and give him a drug brochure on cholesterol.
  2. Thank the client for calling that to her attention, place the information aside, and proceed with the encounter.
  3. Discuss the information with the client to find out if it seems accurate while also suggesting some reliable sources of online information.
  4. Assume the client has done his homework and discuss the information as part of the client’s treatment plan.

 

Question 3

Type: MCSA

Which of the following is not one of the ONC committee’s criteria for defining its meaningful use objectives?

  1. Clients should have access to self-management tools
  2. Participation on a health information exchange (HIE)
  3. Providers should have access to comprehensive client data from all available sources
  4. Clients should be able to correct or edit their electronic health data in real time

 

Question 4

Type: MCSA

Which of the following sites is considered a reliable source of information for nurses?

  1. Google
  2. Wikipedia
  3. ANA.ORG
  4. CNN Health

 

Question 5

Type: MCSA

Which of the following is an example of decision support in relation to an EHR system?

  1. Links to specific protocols, case study results, or guidelines
  2. An annotated bibliography of medical journals
  3. Links to general online medical resources
  4. A list of recommended continuing education classes

 

Question 6

Type: MCSA

The Internet can best be described as a (n) _________

  1. local-area network.
  2. virtual private network.
  3. public network.
  4. wide-area network.

 

Question 7

Type: MCSA

Jorge is a home care nurse within a large geographic area; he needs real-time access to update the records of his clients while away from the home health agency. Which of the following will Jorge need to use his agency’s EHR remotely?

  1. SSL
  2. LAN
  3. VPN
  4. WAN

 

Question 8

Type: MCSA

The nurse is explaining the process of telemedicine to a client. Which of the following would be an example of store-and-forward telemedicine?

  1. Phone teleconference
  2. Video documentary on open-heart surgery
  3. Voice mail message to a referring physician
  4. CAT scan

 

Question 9

Type: MCSA

Store-and-forward telemedicine would not be suited to which of the following situations?

  1. Caring for a client with numerous comorbidities
  2. Treating a high risk client
  3. Performing arthroscopic surgery in real time
  4. Consulting on a client with a rare disease

 

Question 10

Type: MCSA

A client who uses Instant Medical History when visiting her primary care provider ___________

  1. gives her symptoms to a medical assistant for entry.
  2. must complete all the questions before arriving at the office.
  3. has access to the EHR where her medical record resides.
  4. has more face-to-face time with her provider during the visit.

 

Question 11

Type: MCSA

Dana has sent e-mail to her provider with a question about recent blood work results. According to the HIPAA Security Rule, Dana’s provider must _________

  1. respond ASAP to his client’s question.
  2. contact Dana by phone to answer her question.
  3. use decryption to verify Dana’s identity before replying.
  4. not include any PHI if replying by e-mail.

 

Question 12

Type: MCSA

Which of the following is not a characteristic of an e-visit?

  1. It is secure.
  2. It is directed to a specific provider.
  3. It is free.
  4. It becomes part of the client’s chart.

 

Question 13

Type: MCSA

An e-visit would work best in which of the following situations?

  1. Screening a brand new client who has not yet been to a practice
  2. Triaging a worsening condition in the middle of the night
  3. Guiding a client step by step through an emergency
  4. Treating a client who has seasonal allergies

 

Question 14

Type: MCSA

The nurse explains to a client that, per the HITECH Act incentives for promoting the use of an EHR system, clients must receive electronic access to lab results within _______ hours of the information being available to the provider.

  1. 24
  2. 36
  3. 48
  4. 96

 

Question 15

Type: MCMA

The nurse is explaining to a client the manner in which the EHR uses the Internet to enhance client health care – including which of the following applications?

Standard Text: Select all that apply.

  1. Use of the IMH
  2. Secure client-provider messaging
  3. Client access to changing the EHR
  4. Client access to self-management tools
  5. Provider access to client data

 

Question 16

Type: MCSA

Which of the following statements about client-entered data in relation to the EHR is false?

  1. The client is the best judge of what symptoms he had at the beginning of an illness, making this information more accurate when he enters it himself.
  2. The clinician will spend more face-to-face time with the client if she does not need to spend the majority of the encounter entering symptoms herself.
  3. Client entered data enables the clinician to ask the client more questions about the diagnosis.
  4. A client who can review her medical history before she sees her provider will be more prepared for the visit.

 

Question 17

Type: MCSA

Typically, an e-mail communication between a client and a provider _______

  1. becomes part of the EHR.
  2. gathers symptom and HPI information.
  3. allows a client to share objective health information.
  4. provider is not reimbursed for treating the client.

 

Question 18

Type: MCSA

Which of the following is an advantage of synchronous telemedicine?

  1. It may be practiced by providers across state lines.
  2. It is useful for sharing diagnostic images with specialists.
  3. It gives a specialist the opportunity to research a case further.
  4. It allows the provider and the client to meet in real-time.

 

Question 19

Type: MCSA

Home Health nurses are using the Internet for telemedicine. Which of the following is not a valid reason for this?

  1. Internet video conferencing allows the nurse to visually see the client.
  2. Nurses can download data from home medical devices.
  3. It gives the nurse opportunity to skip in home assessments.
  4. It allows the nurse to answer client questions sooner.

 

Question 20

Type: MCSA

Which industry has been the last to make Internet-based transactions readily available?

  1. Healthcare
  2. Banking
  3. Travel
  4. Brokerage/investing

 

Question 21

Type: MCSA

The nurse know that the Internet has a lot of potential for healthcare, including:

  1. Remote access to client charts
  2. Transmission of PHI via email
  3. Transmission of medical reports
  4. Consultation with specialists
  5. Ability to care for clients remotely

 

Question 22

Type: MCMA

The client can utilize the Internet to:

Standard Text: Select all that apply.

  1. locate providers.
  2. research diseases.
  3. see physicians for the initial visit.
  4. self diagnose.
  5. participate in on-line discussion groups.

 

Question 23

Type: MCMA

The nurse and client are discussing criteria to use when evaluating information available on the Internet, including:

Standard Text: Select all that apply.

  1. Checking the date of the information
  2. The information is provided by a drug company
  3. The article lists an organization as the author
  4. The website is from a trusted medical institution
  5. The article lists the author and credentials

 

Question 24

Type: MCSA

The nurse is caring for a client who is unfamiliar with a prescribed medication. An example of a reliable source for information is:

  1. www.wikipedia.com
  2. www.ana.org
  3. www.drugstore.com
  4. www.medicine.com

 

Question 25

Type: MCSA

Useful resources for the nurse to use at the client’s bedside include

  1. Websites
  2. Journals
  3. Integrated decision support resources
  4. Continuing education courses

 

Question 26

Type: MCSA

The nurse is caring for a client in an acute care facility. The EHR is accessible on the nurse’s tablet pc via:

  1. a LAN
  2. a VPN
  3. The World Wide Web
  4. a WAN

 

Question 27

Type: MCSA

A client is being seen at the health care office for the first time. The office utilizes an IMH. The client will input this information:

  1. Prior to registering at the reception desk
  2. After seeing the nurse
  3. Upon checkout from the office
  4. Prior to seeing the nurse

 

Question 28

Type: MCSA

The IMH allows the client to enter the following information in the EHR:

  1. Vital signs
  2. HPI
  3. The current encounter note
  4. Comprehensive physical exam information

 

Question 29

Type: MCSA

The nurse explains the main benefit of the IMH is:

  1. to save money.
  2. to save the receptionist time.
  3. to evaluate the client’s ability to read.
  4. to allow the provider more time to spend with the client.

 

Question 30

Type: MCSA

The nurse needs to let the client know about some lab results. The appropriate method of communicating with the client with the EHR is:

  1. e-mail
  2. Secure messaging
  3. Telephone
  4. Text message

 

Gartee, Electronic Health Records and Nursing, 1e
Chapter 12

Question 1

Type: MCSA

The nurse explains to the client that ann EHR can create specific preventive screening or health maintenance guidelines based on all of the following information about a client except:

  1. Past medical history
  2. Gender
  3. Personal preferences
  4. Social history

 

Question 2

Type: MCSA

Janice made an appointment for her regular mammogram after receiving an email from her provider’s office. This is an example of:

  1. Acute care
  2. Coordinating
  3. Counseling
  4. Preventive screening

 

Question 3

Type: MCSA

In which of the following ways would an EHR form that was created for a well-baby check be different from a form used for an adult client?

  1. It has check boxes to record findings.
  2. It is intended for a narrowly defined age group.
  3. It includes selected findings related to the client.
  4. It does not include vital sign information.

 

Question 4

Type: MCSA

Which of the following is an example of FS Hx and to whom does this relate?

  1. Tobacco; parents
  2. Enrolled in day-care; parents
  3. Exposure to second-hand smoke; caregivers
  4. Living with parents; client

 

Question 5

Type: MCSA

The nurse is preparing to measure and record (in the EHR) the vital signs of a 7-month-old baby during a wellness check. Which of the following is incorrect?

  1. You will assess the baby’s temperature tympanically.
  2. You will assess baby’s growth by measuring his height.
  3. You do not need to take the baby’s blood pressure.
  4. You will need to include a measurement of the baby’s head circumference.

 

Question 6

Type: MCSA

The CDC provides a weight-for-stature clinical growth chart for people in which of the following age categories?

  1. Birth to 36 months
  2. Children and adolescents, 2 to 20 years
  3. Preschoolers, 2 to 5 years
  4. Teenagers, 13 to 20 years

 

Question 7

Type: MCSA

Jeremy’s pediatrician notes that he is in the 75th percentile for his height. What does this mean?

  1. Jeremy weighs the same as more than 25% of the reference population for girls and boys.
  2. Jeremy is shorter than 25% of the reference population for boys.
  3. Jeremy’s height and weight are normal for a child of his age.
  4. Jeremy has been following a consistent curve in terms of his height.

 

Question 8

Type: MCSA

Molly is an obese 8-year-old. How might a pediatric growth chart generated by an EHR system be useful in educating Molly’s parents about Molly’s condition?

  1. The growth chart illustrates Molly’s risks of developing juvenile diabetes.
  2. The growth chart proves Molly needs more regular physical exercise.
  3. The growth chart places Molly’s measurements in context with other 8-year-old girls.
  4. The growth chart teaches Molly’s parents the importance of a healthier diet.

 

Question 9

Type: MCSA

The nurse is reviewing the use of the BMI for age charts. Which of the following statements about BMI is incorrect?

  1. BMI is used primarily for overweight children.
  2. BMI in childhood is related to a person’s BMI in adulthood.
  3. The BMI number shows body weight adjusted for height.
  4. BMI-for-age is a relatively new screening tool.

 

Question 10

Type: MCSA

At which point do both males and females begin using the same BMI chart?

  1. Up to age 2
  2. Before age 12
  3. After age 20
  4. Beginning at age 65

 

Question 11

Type: MCSA

Which of the following is not an example of an adult BMI category?

  1. Malnourished
  2. Underweight
  3. Overweight
  4. Obese

 

Question 12

Type: MCSA

The nurse is discussing immunizations with the parents of a newborn who have decided to breast feed the child. Which of the following statements is not true?

  1. Neonates are born with a natural immunity.
  2. Newborns receive antibodies from their mothers.
  3. Babies who are breastfed do not require immunization.
  4. Childhood immunization prevents many serious diseases from occurring.

 

Question 13

Type: MCSA

The nurse explains that the acronym DTaP stands for

  1. Rotavirus
  2. Inactivated Poliovirus
  3. Meningococcal
  4. Diphtheria, Tetanus and Pertussis

 

Question 14

Type: MCSA

Which of the following is true about childhood immunizations?

  1. Not all children in the U.S. need to be vaccinated.
  2. In some regions of the U.S. vaccines are administered all at once.
  3. Some vaccines must be given more than one time.
  4. The CDC is the sole authority that recommends childhood immunizations.

 

Question 15

Type: MCSA

Which of the following vaccines is recommended to be given at birth?

  1. RV
  2. HepB
  3. DTaP
  4. IPV

 

Question 16

Type: MCSA

Which of the following is not true of a PHR?

  1. Its use by clients is encouraged by the ONC.
  2. It requires a secure web site.
  3. It is must be maintained by a client’s healthcare provider.
  4. It is available to a client anywhere with Internet access.

 

Question 17

Type: MCSA

Joyce has been keeping a graph of her blood pressure at home for a few months. This means that Joyce:

  1. can adjust her medication as necessary.
  2. e-mails a graph to her physician each day.
  3. needs to see her physician far less often.
  4. is better able to tell if her current treatment is effective.

 

Question 18

Type: MCSA

All of the following are true about “evidence-based guidelines” except:

  1. They are mainly useful for dealing with demographic groups in general.
  2. They represent an analysis of current scientific research.
  3. They offer guidelines both for and against taking certain measures.
  4. They serve as the basis for recommendations based on age, sex, and risk factors for disease.

 

Question 19

Type: MCSA

Ideally, a client’s personal health record (PHR) contains information for the person’s _______.

  1. family
  2. lifetime
  3. provider
  4. chronic diseases

 

Question 20

Type: MCSA

To make sure preventive care services are delivered appropriately, __________ should be available at the point of care.

  1. CDC recommendations
  2. risk assessment data
  3. evidence-based information
  4. screening and testing

 

 

Question 21

Type: MCMA

The nurse is reviewing the birth and medical and surgical history for a pediatric client at a 6-month well-baby visit. Appropriate data to collect includes information about:

Standard Text: Select all that apply.

  1. Type of birth
  2. Smoking history of parents
  3. History of previous illnesses
  4. Type of pregnancy
  5. Head circumference

 

Question 22

Type: MCMA

The nurse is reviewing the mother’s educational needs during a well-baby checkup. Items that would be included in this portion of the encounter include:

Standard Text: Select all that apply.

  1. Nutrition
  2. Child safety
  3. Vital signs
  4. Teething
  5. Motor tone

 

Question 23

Type: MCSA

The nurse is checking the calculations of a client’s BMI. The correct formula is:

  1. ht2/wt
  2. wt2/ht *703
  3. wt/ht2
  4. lbs/kg

 

Question 24

Type: MCSA

The nurse is calculating a client’s BMI. The client weighs 102 pounds and is 5 feet tall. The client’s BMI is

  1. 19.2
  2. 20
  3. 199
  4. 19.9

 

Question 25

Type: MCMA

The nurse is reviewing a pediatric client’s immunization record. The family was traveling immediately after the child’s birth, and he did not receive any immunizations at 2 and 4 months. The nurse explains that the immunizations:

Standard Text: Select all that apply.

  1. can all be given at the current encounter to ‘catch up’.
  2. need to be given over time.
  3. cannot be given and the child will be unprotected.
  4. generally have a range that is considered appropriate for administration.
  5. will be administered according to a catcher-up schedule.

 

Question 26

Type: MCSA

The nurse practitioner is reviewing the pediatric client’s immunization schedule. By clicking the ‘Y’ on form next to the appropriate vaccine the following occurs:

  1. The provider documents the immunization
  2. The provider sends an order to the pharmacy for the vaccine
  3. The provider writes a prescription
  4. The provider sets up the catch-up schedule

 

Question 27

Type: MCMA

The diabetic client is discussing her care plan with her provider. Potential actions that the client should take to be engaged in her own care includes:

Standard Text: Select all that apply.

  1. Calling the provider’s office with all the blood sugar measurements
  2. Recording the measurements in a notebook
  3. Calling the provider when the blood sugar measurements are not within normal limits
  4. Monitoring and recording vital signs
  5. Reviewing the logs with the provider on monitoring visits

 

Question 28

Type: MCSA

The nurse is explaining the concept of the patient-centered medical home to a client, stating:

  1. The client stays with the provider for years at a time
  2. The client sees specialists in one facility
  3. The client uses paper-based records
  4. The client is seen in a primary healthcare setting that facilitates partnerships

 

Question 29

Type: MCMA

A client is transferring from one provider to another. This is facilitated with the EHR by:

Standard Text: Select all that apply.

  1. Providing clients with electronic access to their health information within hours
  2. Providing clients with printouts of their EHR
  3. Providing clients with electronic copies of discharge instructions
  4. Mailing the client reminders for preventive or follow up care
  5. Emailing the new provider all the client’s information

 

Question 30

Type: MCMA

The basics that the client should look for when evaluating a PHR include:

Standard Text: Select all that apply.

  1. The data is managed by the provider
  2. The provider or company controls who can have access
  3. The client can see who entered the data
  4. The data is secure and private
  5. The PHR is universally accessible via the internet