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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Some of the following documentation phrases include subjective terminology that needs to be changed to objective terminology. Select the phrases with subjective terms and underline the subjective word(s) that need(s) to be changed to objective.
- A. Snored loudly most of night between 0030 and 0530.
- B. Green purulent drainage increased from yesterday. ABD pad has 6' circle of drainage.
- C. Procedure tolerated well.
- D. ADA diet-ate 75% tolerated poorly.
- E. Bouncing foot almost continually. Rubbing hands and flicking finger with thumb at intervals. Verbally denies feeling nervous or anxious.
- F. Got mad while ambulating in the hall.
- G. Has a bad attitude.
Correct Answer: C,D,F,G
Rationale: Subjective terms: 'tolerated well' (C), 'tolerated poorly' (D), 'got mad' (F), 'bad attitude' (G). These should be replaced with objective descriptions. A, B, and E are objective.
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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. The process of providing effective patient care that is delivered and evaluated continuously, systematically, and smoothly from one hour to the next, including through the staffing changes between shifts, is known as what?
- A. Internal assessment
- B. Accreditation
- C. Quality assurance
- D. Continuity of care
Correct Answer: D
Rationale: Continuity of care (D) ensures patient care is delivered consistently across time and staff changes. Internal assessment (A), accreditation (B), and quality assurance (C) are related to evaluation and standards but not the direct process of care delivery.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. What time would the military time 2210 be?
- A. 10:22 a.m.
- B. 10:22 p.m.
- C. 2:21 a.m.
- D. 10:10 p.m.
Correct Answer: B
Rationale: 2210 in military time is 10:22 p.m. (B), as it is 10 minutes past 10 p.m. 10:22 a.m. (A) is 1022, 2:21 a.m. (C) is 0221, and 10:10 p.m. (D) is 2210.
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.
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.
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.