Nokea
A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)
- A. Wait until the end of the shift to document
- B. Cover errors with correction fluid, and write in the correct information
- C. Use as many abbreviations as possible to save space
- D. Document objective data, leaving out opinions
- E. The date and time should be included with each entry
Correct Answer: D,E
Rationale: D: Documentation must be objective (e.g., 'grimaced when moving') to avoid bias. E: Including date and time ensures a clear timeline for legal and care continuity. A is incorrect because timely documentation prevents errors. B is incorrect as errors should be corrected with a single line and initials. C is incorrect because only approved abbreviations should be used to avoid confusion.
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Select the type of assessment which is performed continuously throughout nurse-patient contact:
- A. focused
- B. body systems
- C. subjective
- D. complete
Correct Answer: A
Rationale: Focused assessments (A) are ongoing, targeting specific issues like pain or breathing during contact. Body systems (B), subjective (C), and complete (D) assessments are not continuous.
Patient is confined to bed rest
The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?
- A. as difficult to maintain
- B. as a risk factor
- C. as a nursing responsibility
- D. as contributing to the patient's recovery
Correct Answer: B
Rationale: Bed rest (B) is a risk factor for complications like pressure ulcers or DVT, which should be noted in the care plan. A is subjective, C is an intervention, and D is incomplete as bed rest can hinder recovery if prolonged.
Patient with edema has a problem of fluid overload
A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:
- A. use a Nursing Diagnosis from a source other than NANDA-I
- B. limit the number of interventions
- C. select interventions which will be easy to implement
- D. involve the patient in the process
Correct Answer: D
Rationale: Involving the patient in the care plan (D) ensures better adherence and personalization, which is critical for effective fluid reduction. A is incorrect because NANDA-I provides standardized diagnoses for accuracy. B is incorrect as interventions should be sufficient, not arbitrarily limited. C is incorrect because interventions should be effective, not merely easy.
Patient was administered a stat insulin dose
The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:
- A. the insulin was administered based per the nurse's testimony
- B. none of the answers are correct
- C. the insulin was administered based on the witness testimony
- D. the insulin was not administered because it was not charted
Correct Answer: D
Rationale: Legally, 'if it wasn't documented, it wasn't done' (D). Without MAR documentation, the insulin administration cannot be verified, despite testimony (A, C). B is incorrect as D is accurate.
Patient's vital signs are B/P 120/80, P 88, and R 18; Non-responsive patient; Disoriented patient; Critically ill patient
A focused assessment should be done by the nurse in all of the following situations EXCEPT:
- A. patient's vital signs are B/P 120/80, P 88 and R 18
- B. non-responsive patient
- C. disoriented patient
- D. critically patient ill
Correct Answer: A
Rationale: Stable vital signs (A) do not require a focused assessment unless indicated. B, C, and D signal urgent conditions needing targeted evaluation.