BAB 4 Professional Standards in Nursing Practice

• The medical record is a legal document and requires information

describing the care that is delivered to a patient.
• The computerized health record (or electronic health record) is
a digital version of a patient’s medical record.
• All information pertaining to a patient’s health care management
that is gathered by examination, observation, conversation,
or treatment is confidential.
• Access to patient records is limited to individuals involved in
the care of the patient.
• Interdisciplinary communication is essential within the health
care team.

Are You Ready to Test Your Nursing Knowledge?

1. A manager who is reviewing the nurses’ notes in a patient’s
medical record finds the following entry, “Patient is difficult to
care for, refuses suggestion for improving appetite.” Which of
the following directions does the manager give to the staff
nurse who entered the note?
1. Avoid rushing when charting an entry.
2. Use correction fluid to remove the entry.
3. Draw a single line through the statement and initial it.
4. Enter only objective and factual information about the
patient.
2. A new graduate nurse is providing a telephone report to
a patient’s health care provider and accepting telephone
orders from the provider. Which of the following actions
requires the new nurse’s preceptor to intervene? The new
nurse:
1. Uses SBAR (Situation-Background-Assessment-
Recommendation) as a format when providing the
report.
2. Gives a newly ordered medication before entering the order
in the patient’s medical record.
3. Reads the orders back to the health care provider after
receiving them and verifies their accuracy.
4. Asks the preceptor to listen in on the phone conversation.
3. As you enter the patient’s room, you notice that he is anxious
to say something. He quickly states, “I don’t know what’s going
on; I can’t get an explanation from my doctor about my test
results. I want something done about this.” Which of the following
is the most appropriate documentation of the patient’s
emotional status?
1. The patient has a defiant attitude and is demanding his test
results.
2. The patient appears to be upset with his nurse because he
wants his test results immediately.
3. The patient is demanding and complains frequently about
his doctor.
4. The patient stated that he felt frustrated by the lack of
information he received regarding his tests.
4. You are reviewing Health Insurance Portability and Accountability
Act (HIPAA) regulations with your patient during
the admission process. The patient states, “I’ve heard a lot
about these HIPAA regulations in the news lately. How will
they affect my care?” Which of the following is the best
response?
1. HIPAA allows all hospital staff access to your medical
record.
2. HIPAA limits the information that is documented in
your medical record.
3. HIPAA provides you with greater control over your personal
health care information.
4. HIPAA enables health care institutions to release all of
your personal information to improve continuity
of care.
5. A patient asks for a copy of her medical record. The best
response by the nurse is to:
1. State that only her family may read the record.
2. Indicate that she has the right to read her record.
3. Tell her that she is not allowed to read her record.
4. Explain that only health care workers have access to her
record.

6. Which of the following charting entries is most accurate?

1. Patient walked up and down hallway with assistance,
tolerated well.
2. Patient up, out of bed, walked down hallway and back to
room, tolerated well.
3. Patient up, walked 50 feet and back down hallway with
assistance from nurse. Spouse also accompanied patient
during the walk.
4. Patient walked 50 feet and back down hallway with assistance
from nurse; HR 88 and regular before exercise, 94 and
regular following exercise.
7. Match the correct entry with the appropriate SOAP
(Subjective—Objective—Assessment—Plan) category.
1. S a. Repositioned patient on right side. Encouraged
patient to use patient-controlled analgesia (PCA)
device.
2. O b. “The pain increases every time I try to turn on my
left side.”
3. A c. Acute pain related to tissue injury from surgical
incision.
4. P d. Left lower abdominal surgical incision, 3 inches in
length, closed, sutures intact, no drainage. Pain
noted on mild palpation.
8. On the nursing unit you are able to access a patient’s medical
record and review the education that other nurses provided to
the patient during an initial hospitalization and three subsequent
clinic visits. This type of feature is most common in
what type of record system?
1. Information technology.
2. Electronic health record.
3. Personal health information.
4. Administrative information system.
9. You are giving a hand-off report to another nurse who will be
caring for your patient at the end of your shift. Which of the
following pieces of information do you include in the report?
(Select all that apply.)
1. The patient’s name, age, and admitting diagnosis
2. Allergies to food and medications
3. Your evaluation that the patient is “needy”
4. How much the patient ate for breakfast
5. That the patient’s pain rating went from 8 to 2 on a scale
of 1 to 10 after receiving 650 mg of Tylenol
10. You are supervising a beginning nursing student who is documenting
patient care. Which of the following actions requires
you to intervene? The nursing student:
1. Documented medication given by another nursing
student.
2. Included the date and time of all entries in the chart.
3. Stood with his back against the wall while documenting on
the computer.
4. Signed all documentation electronically.
11. A group of nurses is discussing the advantages of using computerized
provider order entry (CPOE). Which of the following
statements indicates that the nurses understand the major
advantage of using CPOE?
1. “CPOE reduces transcription errors.”
2. “CPOE reduces the time necessary for health care providers
to write orders.”
3. “Health care providers can write orders from any computer
that has Internet access.”
4. “CPOE reduces the time nurses use to communicate with
health care providers.”

12. You are helping to design a new patient discharge teaching

sheet that will go home with patients who are discharged to
home from your unit. Which of the following do you need to
remember when designing the teaching sheet?
1. The new federal laws require that teaching sheets be
e-mailed to patients after they are discharged.
2. You need to use words the patients can understand when
writing the directions.
3. The form needs to be given to patients in a sealed envelope
to protect their health information.
4. The names of everyone who cared for the patient in the
hospital need to be included on the form in case the patient
has questions at home.
13. A nurse caring for a patient on a ventilator electronically documents
the head of bed elevated at 20 degrees. Suddenly an alert
warning appears on the screen warning the nurse that this
patient is at a high risk for aspiration because the head of the
bed is not elevated high enough. This warning is known as
what type of system?
1. Electronic health record
2. Clinical documentation
3. Clinical decision support system
4. Computerized physician order entry

14. While reviewing the pulmonary section of a patient’s

electronic chart, the physician notices blank spaces since the
initial assessment the previous day when the nurse documented
that the lung assessment was within normal limits.
There also are no progress notes about the patient’s respiratory
status in the nurse’s notes. The most likely reason for this
is because:
1. The nurses forgot to document on the pulmonary system.
2. The nurses were charting by exception.
3. The computer is not working correctly.
4. The physician does not have authorization to view the
nursing assessment.
15. What is an appropriate way for a nurse to dispose of printed
patient information?
1. Rip several times and place in a standard trash can
2. Place in the patient’s paper-based chart
3. Place in a secure canister marked for shredding
4. Burn the documents

Answers: 1. 4; 2. 2; 3. 4; 4. 3; 5. 2; 6. 4; 7. 1b, 2d, 3c, 4a; 8. 2;

9. 1, 2, 5; 10. 1; 11. 1; 12. 2; 13. 3; 14. 2; 15. 3.