Nokea

HOME
ABOUT US
SERVICES
BLOGS
FAQS
CONTACT US

Guest User

Sign In

Documentation

Home
Textbooks
Fundamentals of Nursing Care: Concepts, Connections & Skills
Documentation

Test Board

Self Paced

Question 1 of 5

Which of the following phrases are written objectively?

A. Ate 45% full-liquid diet. Did not act very hungry and acted like she should not have drunk all that she did.'

B. Complaining of really severe pain and wants something for it.'

C. Ambulated unassisted the length of hallway without complaints of fatigue or shortness of breath.'

D. Does not feel good today. Angry and depressed.'

Correct Answer:

Rationale:

Question 2 of 5

When you use an EHR, you may enter information in which of the following ways?

A. Hand-held computer

B. Computer at a computer station in the hallway

C. Computer at the nurses' station

D. Bedside terminal in the patient's room

Correct Answer:

Rationale:

Question 3 of 5

Which of the following times during a 7 a.m. to 7 p.m. shift would be appropriate to document on a patient's chart?

A. As soon as possible after an occurrence or event

B. Once at the beginning of the shift, again about midway through the shift, and the last time at the end of the shift

C. Before the physician makes morning rounds at 10:15 a.m.

D. Following the performance of physical assessments

Correct Answer:

Rationale:

Question 4 of 5

Which of the following entries are good examples of succinct charting?

A. Bed bath was given and teeth brushed. Hair was shampooed and tangles combed out. Soaked fingernails in warm soapy water for 20 minutes, then filed them and cleaned them using an orange stick. Legs were shaved and lotion applied to all pressure points and areas of dry skin. Gave her a back rub.'

B. Sacral wound measures 2 x 4 cm with 1-cm depth. Wound bed pale and dry, with 1-cm black eschar center circumferenced by 0.5-cm dark erythema. No granulation noted. Moderate amount foul-smelling green purulent drainage.'

C. Patient is having moderate amount of cramping in her abdomen. It seems to be from her uterus. When I inquired, the patient said it is time for her to start her menses. The patient also said she usually does not experience premenstrual cramping.'

D. BP - 124/72, T - 98.8°F orally, P - 64 strong & reg, R - 17 reg & even.'

Correct Answer:

Rationale:

Question 5 of 5

What type of documentation would you, as a nurse, be responsible for performing in the section marked Physician's Orders?

A. The patient's plan of care to be followed

B. The vital signs taken during your shift along with the I&O totals

C. Transcription date, time, and your initials

D. When you noted the orders

Correct Answer:

Rationale:

Upgrade for Full Access

Viewing 5 of 9 questions. Subscribe to unlock all content.

Complete access to all questions
Detailed explanations
Progress tracking

Login to Subscribe

Related Questions

Which document would be found in the Advanced Directive section of a source-oriented medical record?
When you use an EHR, you may enter information in which of the following ways?
When working in long-term care, the nurse is required to document assessment data on a resident how often?
What type of documentation would you, as a nurse, be responsible for performing in the section marked Physician's Orders?
In a source-oriented medical record, which of these would be found in the Nurse's Notes section?

Similar Exams

The Vista of Nursing
Health-Care Delivery, Settings, and Economics
Ethics, Law, and Delegation in Nursing
The Nursing Process: Critical Thinking and Decision Making
Communication and Relationships
Promoting Health and Wellness
Ethnic, Cultural, and Spiritual Aspects of Care
Growth and Development Throughout the Life Span
Loss, Grief, and Dying
Complementary and Alternative Medicine
Patient Teaching
Safety
Medical Asepsis and Infection Control
Personal Care
Moving and Positioning Patients
Vital Signs
Applying Heat and Cold Therapies
Pain Management, Rest, and Restorative Sleep
Admission, Transfer, and Discharge

Copyright © 2025 Nokea. All rights reserved.