Question 1

The charge nurse is evaluating patient documentation of a new staff nurse.Based on which of the following does the charge nurse note,on review of the new nurse's charting,that appropriate documentation is evident?

A) A pencil was used to make the entries.
B) Correction fluid was used to correct written errors.
C) An error made by the attending physician was documented.
D) All of the entries he or she made in the record were dated and signed.

D

Accepted Answer

Documentation should be legible, accurate, complete, clear, concise, and timely. All entries in the record must be dated and signed with the nurse's name and title. The use of a pencil is not appropriate as it can be erased or altered easily. Correction fluid can also make documentation unclear and illegible. An error made by the attending physician should be reported and documented appropriately, but it does not indicate appropriate documentation by the nurse.

Question 2

To avoid legal risks and possible lack of confidentiality associated with computerized documentation,which of the following statements is true of many current software programs?&#10;A) All nursing staff use the same access code.&#10;B) Only centralized medical records use the patient data.&#10;C) Thumbprint identification restrictions are in place.&#10;D) Staff password changes are periodically required.

Accepted Answer

Staff password changes being periodically required is a common feature of many software programs that helps to ensure security and confidentiality of patient data. The other options listed - all nursing staff using the same access code and only centralized medical records using the patient data - pose significant risks to patient privacy and are not common practices in modern software programs. Thumbprint identification restrictions may be in place in some cases, but this is less common than requiring regular password changes.

Question 3

The nurse is documenting on the patient's record and notes that he or she has made an error.What action should the nurse take?&#10;A) Draw a line through the error, and initial and date it.&#10;B) Erase the error, and write over the material in the same spot.&#10;C) Use a dark-coloured marker to cover the error, and continue immediately after that point.&#10;D) Footnote the error at the bottom of the page, including initials and the date.

Accepted Answer

Drawing a line through the error, initialing and dating it is the best option for correcting errors in documentation. This ensures that the original information is still visible and verifiable in case of any auditing or legal issues. Erasing the error or covering it with a marker can lead to questions of authenticity and may suggest that the nurse is trying to hide something. Footnoting the error at the bottom of the page is not recommended as it may not be easily noticed by other healthcare professionals who may need to review the chart.

Question 4

Which of the following is evaluated as a legally appropriate notation?&#10;A) &#34;Dr. Green made an error in the amount of medication to administer.&#34;&#10;B) &#34;Patient verbalized sharp, stabbing pain along the left side of chest.&#34;&#10;C) &#34;Nurse Williams spoke with the patient about the surgery.&#34;&#10;D) &#34;Patient upset about the physiotherapy.&#34;

Accepted Answer

B is evaluated as a legally appropriate notation as it is a clear description of the patient's symptoms in their own words. The other options lack specific details and are not as objective.

Question 5

Which of the following types of documentation is represented by the statement,&#34;Patient is wheezing and experiencing some dyspnea on exertion&#34;?&#10;A) The &#34;S&#34; in SOAP documentation&#10;B) Focus documentation&#10;C) The &#34;P&#34; of PIE documentation&#10;D) The &#34;R&#34; in DAR documentation

Accepted Answer

The answer of Which of the following types of documentation...

Question 6

Which of the following is true about a flow sheet?&#10;A) Information is outdated.&#10;B) The quantity of narrative notes is increased.&#10;C) There is an increased chance of errors from transfer of information.&#10;D) Team members can quickly identify trends over time of care.

Accepted Answer

Flow sheets allow for easy visualization of trends over time and can aid team members in analyzing and improving care. Options A-C are all incorrect.

Question 7

When documenting care that has been implemented by the nurse,what is the term used to describe an older adult who is living in a long-term care or residential facility?&#10;A) Client&#10;B) Patient&#10;C) Resident&#10;D) Individual

Accepted Answer

The term used to describe an older adult who is living in a long-term care or residential facility is "resident." This terminology acknowledges that the individual is living in their long-term care facility, rather than simply receiving healthcare services as a patient or client.

Question 8

Which of the following is true in regard to a source record?&#10;A) Interprofessional documentation is involved.&#10;B) Content is organized by discipline.&#10;C) It documents deviations from the norm.&#10;D) It documents the source of the patient problem.

Accepted Answer

A source record organizes content by discipline, meaning each healthcare discipline documents in its own section.

Question 9

Which of the following terms describes an unexpected occurrence when the unit documentation is a critical pathway?&#10;A) Incident&#10;B) Variance&#10;C) Deviation&#10;D) Charting by exception

Accepted Answer

A variance is an unexpected occurrence or deviation from the expected pathway or plan of care. This can include things like a delay in medication administration or a patient refusing a treatment. Incidents may also describe unexpected occurrences, but they do not necessarily involve the unit documentation or critical pathways. Deviation and charting by exception are terms that describe specific documentation practices, and do not necessarily relate to unexpected occurrences.

Question 10

Guidelines should be followed when documenting patient care.Which one of the following does the nurse recognize as the most appropriate notation?&#10;A) &#34;1230 hours: Patient's vital signs taken&#34;&#10;B) &#34;0700 hours: Patient drank adequate amount of fluids&#34;&#10;C) &#34;0900 hours: Morphine given for lower abdominal pain&#34;&#10;D) &#34;0830 hours: Increased IV fluid rate to 100 mL per hour&#34;

Accepted Answer

The most appropriate notation is one that is concise, accurate, and contains relevant information. Option D provides specific details about the patient's care, including the time, the intervention, and the rationale for it. This allows for easy tracking of the patient's progress and is helpful when coordinating care with other members of the healthcare team. Option A is too vague and fails to provide any context for the vital signs, while option B is subjective and does not offer any concrete information about the patient's condition. Option C is also specific but lacks the explanation for the intervention.

Question 11

What does the final &#34;R&#34; represent when using the I-SBAR-R communication technique?&#10;A) Recovery&#10;B) Repeat back&#10;C) Reorganization&#10;D) Reintegration

Accepted Answer

The answer of What does the final &#34;R&#34; represent when...

Question 12

A slight hematoma has developed on the patient's left forearm.The nurse labels the problem as an infiltrated intravenous (IV)line.The nurse elevates the forearm.The patient states,"My arm feels better." Which of these is documented as the "R" in the data-action-response (DAR)notes of focus charting?

A) "My arm feels better."
B) "Slight hematoma on left forearm"
C) "Infiltrated IV line"
D) "Elevation of left forearm"

Accepted Answer

The answer of A slight hematoma has developed on the...

Question 13

Where does the nurse record a description of the teaching provided to the patient on performance of self-medication administration?&#10;A) Kardex form&#10;B) Incident report&#10;C) Nursing history form&#10;D) Discharge summary form

Accepted Answer

The answer of Where does the nurse record a description...

Question 14

The nurse is preparing the information that will be provided to the staff on the next shift.Which of the following should the nurse include in the change-of-shift report to nursing colleagues?&#10;A) A description of the steps of procedures done&#10;B) A review of routine care for the patient&#10;C) All routine care procedures required by the patient&#10;D) Essential background information about the patient

Accepted Answer

The answer of The nurse is preparing the information that...

Question 15

It is late at night on the medical unit in the hospital,and the physician calls to leave orders for one of his patients.The licensed practical nurse answers the phone and appropriately responds with which of the following statements?

A) "Let me get the registered nurse on the phone."
B) "I am unable to take the order at this time. Please call in the morning."
C) "Please repeat the order for me, so that I can make sure it is written correctly."
D) "Let me have your phone number, and I will have the supervisor call you back."

Accepted Answer

The answer of It is late at night on the...

Deck 15: Documenting and Reporting