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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.
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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following statements is(are) true in reference to The Joint Commission?
- A. The Joint Commission audits medical records to verify facility compliance in meeting established healthcare standards.
- B. The Joint Commission sets the standards by which the quality of health care is measured nationally and internationally.
- C. The Joint Commission seeks to improve safety and quality of care that health-care organizations provide to the public.
- D. The Joint Commission is a group of commissioned individuals who collectively represent all the medical insurance companies who set the standards for medical care reimbursement.
Correct Answer: A,B,C
Rationale: The Joint Commission audits records (A), sets healthcare quality standards (B), and aims to improve safety and quality (C). D is incorrect as it does not represent insurance companies.
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. 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.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which are accurate statements about EHR?
- A. It is a record of the patient's interactions with the primary care doctor, but not with specialists.
- B. It is a record of an individual's lifetime health information, easily updated and transferable.
- C. It has built-in security and confidentiality, so nurses do not have to take any additional precautions.
- D. The nurse is only supposed to access the records of the patients that he or she cares for, not every patient on the nursing unit.
- E. It is only available on hand-held computers.
Correct Answer: B,D
Rationale: EHR is a lifetime health record (B) and nurses should only access assigned patients' records (D). A is false as it includes specialists, C is false as precautions are needed, and E is false as EHR is not limited to hand-held devices.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of these following types of data should be included in weekly summaries in a long-term care facility?
- A. Use of prosthesis
- B. Activity level
- C. Length of time the resident has been at the facility
- D. Whether continent or incontinent of bowel and bladder
- E. Whether the resident can speak
- F. Whether the resident routinely has relatives and visitors
- G. Social activities in which the resident participates
Correct Answer: A,B,D,E,F,G
Rationale: Weekly summaries should include prosthesis use (A), activity level (B), continence (D), speech ability (E), visitors (F), social activities (G), self-care ability (I), and diet (J). Length of stay (C), staff conflicts (H), and payment status (K) are not typically included.