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A nurse organizes patient data using the SOAP format. Which of the following would be recorded under S of this acronym?
- A. patient complaints of pain
- B. patient symptoms
- C. patients chief complaint
- D. patient interventions
Correct Answer: A
Rationale: The 'S' in SOAP stands for subjective data, which includes the patient's complaints, such as pain.
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A nurse has access to computerized standardized plans of care. After printing one for a patient, what must be done next?
- A. Date it and put it in the patients record.
- B. Sign it and put it in the Kardex.
- C. Individualize it to the specific patient.
- D. Use it as printed, based on common needs.
Correct Answer: C
Rationale: Standardized care plans must be tailored to the patient's unique needs to ensure appropriate and effective care.
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.
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.
Which of the following abbreviations are on the Joint Commission do not use abbreviations? Select all that apply.
- A. U (unit)
- B. QD (daily)
- C. NPO (nothing per os)
- D. mL (milliliters)
- E. > (greater than)
- F. mcg (micrograms)
Correct Answer: A,B,E
Rationale: The Joint Commission prohibits abbreviations like U, QD, and > due to their potential for misinterpretation, which can lead to medication errors.
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.