Nokea
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following charting 'omissions' (meaning they were not charted) would carry potential legal risks just by the nature of the omission?
- A. The time a patient consumed his or her evening meal
- B. A rash and swelling noted during assessment
- C. The fact that the patient has a history of hemophilia
- D. A physician's order for a medication
- E. The nurse instructed the patient that he needs to increase oral intake
- F. Noting of a physician's order to make a patient NPO
Correct Answer: B,C,D,F
Rationale: Omitting a rash/swelling (B), hemophilia history (C), medication order (D), or NPO order (F) poses legal risks due to potential harm. Meal time (A) and oral intake instruction (E) are less critical.
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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Guidelines for paper documentation include which of the following?
- A. All documentation for your shift must be signed after you have charted your last entry for the shift.
- B. All documentation must be done in cursive writing.
- C. Charting should be done in blocks of time to reduce the number of unnecessary entries.
- D. The date and time should be included with each entry.
Correct Answer: A,D
Rationale: Paper documentation requires signing at shift's end (A) and including date/time (D). Cursive is not mandatory (B), and block charting (C) is not standard.
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). The only time that it is okay to share your computer password with another student or coworker is if he or she is going to document vital signs for you.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False (F): Sharing passwords is never acceptable due to security and accountability concerns.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. When documenting with focus charting, which acronym is generally used?
- A. SOAP
- B. SOAPIER
- C. PIE
- D. DAR
Correct Answer: D
Rationale: Focus charting uses the DAR (Data, Action, Response) acronym (D). SOAP (A), SOAPIER (B), and PIE (C) are used in other charting methods.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following entries are succinct?
- A. I took her temp and it was up to 104.2 degrees Fahrenheit.
- B. After giving a complete bed bath, oral care was performed with toothpaste, toothbrush, and mouthwash. Lotion was applied liberally over arms, back, legs, feet, and hands. Her feet and back were massaged for quite a while.
- C. 18 Fr. Foley cath inserted without difficulty & hung to gravity drainage. Returned 275 mL clear pale yellow urine.
- D. The patient said she is really nauseated badly but that she hasn't vomited yet. She asked for her nausea medication that comes in an injection.
- E. C/O constant sharp, stabbing pain in Rt. great toe, began 1 hr ago, now a 7 on 0-10 scale.
Correct Answer: C,E
Rationale: Succinct entries are the Foley catheter insertion (C) and pain complaint (E). A is informal, B is overly detailed, and D is wordy.