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A nurse is documenting information about a patient in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?
- A. PIE system
- B. minimum data set
- C. OASIS
- D. charting by exception
Correct Answer: B
Rationale: The minimum data set is a standardized tool used in Medicare-certified facilities for comprehensive resident assessment and RAI development.
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A nurse is documenting the intensity of a patients pain. What would be the most accurate entry?
- A. Patient complaining of severe pain.
- B. Patient appears to be in a lot of pain and is crying.
- C. Patient states has pain; walking in hall with ease.
- D. Patient states pain is a 9 on a scale of 1 to 10.
Correct Answer: D
Rationale: Using a standardized pain scale, such as 1 to 10, provides a precise and measurable documentation of the patient's pain intensity, making it the most accurate entry.
A nurse uses informatics to plan nursing care for a patient. Which three terms best describes this science as it is applied to nursing?
- A. data, information, knowledge
- B. process, documentation, analysis
- C. research, controls, variables
- D. hypothesis, nursing, practice
Correct Answer: A
Rationale: Nursing informatics involves transforming data into information and knowledge to support patient care.
Which of the following data entries follows the recommended guidelines for documenting data?
- A. Patient is overwhelmed by the diagnosis of pancreatic cancer.
- B. Patient kidneys are producing sufficient amount of measured urine.
- C. Following oxygen administration, vital signs returned to baseline.
- D. Patient complained about the quality of the nursing care provided on previous shift.
Correct Answer: C
Rationale: This entry is objective, specific, and focused on measurable outcomes, adhering to documentation guidelines.
A student has reviewed a patients chart before beginning assigned care. Which of the following actions violates patient confidentiality?
- A. writing the patients name on the student care plan
- B. providing the instructor with plans for care
- C. discussing the medications with a unit nurse
- D. providing information to the physician about laboratory data
Correct Answer: A
Rationale: Including the patient's name on a student care plan can expose confidential information if not properly secured, violating confidentiality.
What part of the patients record is commonly used to document specific patient variables, such as vital signs?
- A. progress notes
- B. nursing notes
- C. critical paths
- D. graphic record
Correct Answer: D
Rationale: The graphic record is designed to track measurable variables like vital signs in a clear, visual format.