Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of these following are sections of a source-oriented chart?
- A. Database
- B. Graphic sheet
- C. Laboratory
- D. Medication administration record
- E. Nurse's notes
- F. Physician's progress notes
Correct Answer: A,B,C,D,E,F
Rationale: Source-oriented charts include database (A), graphic sheet (B), laboratory (C), medication administration record (D), nurse's notes (E), and physician's notes (F), as they are standard sections for organizing patient data.
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Indicate whether the following statements are True (T) or False (F). Statistics such as rates of hospital-acquired infections, mortality rates, success rates of specific procedures, and number of incidents and accidents serve as factors of a medical facility's reputation.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): These statistics are key indicators of a facility's performance and influence its reputation.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. What is the military time for 1:15 a.m.?
- A. 115
- B. 1315
- C. 1115
- D. 1150
Correct Answer: A
Rationale: 1:15 a.m. is 0115 in military time (A), as it is 1:15 after midnight. 1315 (B) is 1:15 p.m., 1115 (C) is 11:15 a.m., and 1150 (D) is 11:50 a.m.
Indicate whether the following statements are True (T) or False (F). If your cursive writing is not legible, you must print your documentation on a paper chart.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Legibility is critical, so printing is required if cursive is unreadable.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. You can safely delegate documentation of certain data to an unlicensed staff member. Which of the following data cannot be delegated?
- A. Administration of medication
- B. Documenting vital signs
- C. Items on a patient care flow sheet, such as type of bath, ambulation, or percentage of diet consumed
- D. Items on a patient care flow sheet, such as pm use of oxygen, that heart sounds are distinct, or presence of edema
Correct Answer: A
Rationale: Medication administration documentation (A) cannot be delegated, as it requires a licensed professional. Vital signs (B) and flow sheet items (C, D) can typically be delegated to unlicensed staff.
Indicate whether the following statements are True (T) or False (F). In charting by exception, normal findings are not charted and checklists are used for routine care.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Charting by exception focuses on abnormal findings, using checklists for routine care.
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