Nokea
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.
You may also like to solve these questions
Indicate whether the following statements are True (T) or False (F). When documenting patient teaching, the only thing that must be included is the subject that was taught and the methods used to teach the subject.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False (F): Documentation should also include patient understanding and response to teaching.
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.
Indicate whether the following statements are True (T) or False (F). Failure to document administration of a medication does not carry a potential legal risk.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False (F): Failing to document medication administration poses a legal risk due to potential patient harm and accountability issues.
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.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Occurrences that should be documented on an incident report form include some of the following. Which ones are included?
- A. A patient fall
- B. A medication error
- C. A 1/4-inch scrape on a visitor's leg from brushing the leg against the edge of the wheelchair
- D. A lack of supplies needed to perform a procedure
- E. A nursing assistant bumped her head on the television mounted on the wall
- F. An unsafe staffing situation for the number and type of patients on the unit
Correct Answer: A,B,E,F
Rationale: Incident reports are needed for patient falls (A), medication errors (B), staff injuries (E), and unsafe staffing (F). Minor visitor scrapes (C) and supply issues (D) are typically not reported.