Question 1

Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000 hours.At 1000,a patient complains of feeling "light-headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.How should the nurse handle documentation for this episode?

Accepted Answer

The nurse should document the vital signs in both the graphic and progress record to ensure a complete and accurate medical record, reflecting the transient episode and the patient's response.

Question 2

The nurse manager is attempting to determine the staffing needs of the unit.One tool that she may use to determine the level of care needed would be

Accepted Answer

The acuity record is a tool used to determine the level of care needed for each patient on the unit. It assesses the patient's condition, care needs, and level of dependency, which can help the nurse manager determine the appropriate level of staffing needed for the unit. The other options may provide useful information for individual patients, but they do not provide an overall picture of the staffing needs for the unit as a whole.

Question 3

Which of the following is the best example of objective charting?

Accepted Answer

Objective charting involves recording observable and measurable facts. Option D provides specific, observable data about the patient's condition, such as skin color and respiratory rate, without subjective interpretation.

Question 4

Standardized care plans (SCPs)are effective ways to plan care for the patient.To be most effective,however,the SCP must be _________________.

Accepted Answer

Standardized care plans must be individualized to meet the specific needs of each patient to ensure that the care provided is appropriate and effective for their unique situation.

Question 5

Which of the following should be documented at the time of occurrence? (Select all that apply.)

Accepted Answer

Vital signs, administration of medications, preparation for diagnostic tests, and patient response to intervention should all be documented at the time of occurrence to ensure accurate and timely medical records.

Question 6

Which is a primary difference between care in the community and hospital care?

Accepted Answer

In community care, the patient and family are often present and involved in the care process, unlike in hospital settings where care is typically provided away from the patient's family.

Question 7

Which of the following is the best example of accurate documentation?

Accepted Answer

Option A provides specific details about the wound, including its length and absence of redness, edema, or drainage. This level of detail is important for accurately communicating the patient's condition and tracking changes over time. Option B is incomplete as it does not specify the reason for irrigation or provide instructions on how to perform the procedure. Option C and D provide minimal information that is not particularly useful for understanding the patient's condition or progress.

Question 8

Nursing documentation must have which of the following characteristics? (Select all that apply.)

Accepted Answer

Nursing documentation must be factual to accurately convey the patient's condition and progress. It must also be organized to ensure that important information is easily accessible. Documentation must be complete to provide a full picture of the patient's care. Public documentation is not necessary and may violate patient privacy laws.

Question 9

The unregulated care provider (UCP)tells the registered nurse (RN)that when the patient's vital signs were taken,the patient complained that she was in a lot of pain.The UCP then tells the nurse that she charted the patient's complaint when she charted the vital signs.What instruction does the nurse need to provide to the nursing assistant?

Accepted Answer

UCPs are typically not authorized to write in the progress notes, as this is a responsibility reserved for licensed nursing staff like RNs.

Question 10

Which of the following provides a quick,easy reference for health care team members in assessing the patient's status,and includes specific measurements such as vital signs,intake and output,and pain assessment?

Accepted Answer

Flow sheets are used to record routine measurements and observations such as vital signs, intake and output, and pain assessments, providing a quick and easy reference for healthcare team members.

Question 11

The patient is ready to go home from the hospital.What does the nurse provide to the patient and his family before he leaves the facility?

Accepted Answer

The discharge summary provides a comprehensive summary of the patient's hospital stay, including diagnosis, treatment, and instructions for follow-up care. This document is crucial in ensuring continuity of care and minimizing the risk of adverse events after discharge. Standardized care plans, patient care summaries, and flow sheets may be helpful during the patient's hospitalization but are not specific to the discharge process.

Question 12

The patient has been in the hospital for a hip replacement.According to his critical pathway,he should have his Foley catheter discontinued on the fourth day after surgery.Instead,the patient has it removed on the third day and is voiding normally with no problems.This would be a sign of

Accepted Answer

Removing the Foley catheter on the third day instead of the expected fourth day is a positive variance, indicating that the patient is recovering well and able to void normally without complications. This can provide opportunities for earlier discharge and better outcomes.

Question 13

The patient is a 24-year-old man who is diagnosed with possible human immunodeficiency virus (HIV)infection while being treated for active pneumonia.He has stated that the nurse may share test result information with his significant other but nothing else at this time.With whom may the nurse communicate regarding this information?

Accepted Answer

The nurse may communicate with the patient's physician and laboratory personnel as they are involved in the patient's care. The significant other can also be informed as per the patient's consent.

Question 14

The patient was in bed with all side rails up.During the night,the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient was not harmed,what step should the nurse take (if any)?

Accepted Answer

Document in the patient's record an objective description of what you observed and follow-up actions taken without reference to the incident report.Incident reports are not a part of the permanent medical record but are an important source of risk-management data for identifying and addressing the causes of errors made in health care organizations.You complete the report even if an injury does not occur or is not apparent.

Question 15

Multidisciplinary care plans that include key interventions and expected outcomes within an established time frame are known as _______________.

Accepted Answer

Critical pathways are multidisciplinary care plans that outline key interventions and expected outcomes within a specific time frame to standardize care for patients with a particular diagnosis or procedure.

Question 16

A preprinted guideline used to care for patients with similar health problems is known as the

Accepted Answer

A standardized care plan is a preprinted guideline used to care for patients with similar health problems. Acuity records are used to record the level of care needed by a patient. A patient care summary is a summary of a patient's medical history and current treatment. A flow sheet is used to record and track a patient's vital signs and other specific data.

Question 17

Which of the following must be complied with when using the electronic health record (EHR)?

Accepted Answer

Logging out when you leave the computer is essential to protect patient information and maintain confidentiality, which is a key compliance requirement when using EHRs.

Question 18

Nursing documentation (Select all that apply.)

Accepted Answer

Nursing documentation ensures continuity of care,provides legal evidence,and evaluates patient outcomes.Effective documentation ensures continuity of care,maintains standards,and reduces errors.

Quiz 4: Documentation and Informatics