Nokea
During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?
- A. block
- B. by exception
- C. focused
- D. SOAP
Correct Answer: B
Rationale: Charting by exception (B) documents only significant changes or deviations, not routine care. Block (A) covers entire shifts, focused (C) targets specific issues, and SOAP (D) follows a structured format.
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JCAHO regulates standards of care to:
- A. ensure subjective documentation
- B. make sure that all nurses use the same charting system
- C. ensure quality patient care
- D. make sure insurance companies get paid correctly
Correct Answer: C
Rationale: JCAHO (C) focuses on improving patient safety and care quality through standards. A is incorrect as objective documentation is emphasized. B is incorrect as charting systems vary. D is incorrect as reimbursement is not JCAHO's focus.
Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:
- A. CNA
- B. Technician
- C. RN
- D. LPN/LVN
Correct Answer: C
Rationale: The RN (C) is responsible for analyzing data and formulating nursing diagnoses, as it requires critical thinking within their scope of practice. CNAs (A) and Technicians (B) assist with care but do not diagnose. LPNs/LVNs (D) collect data but do not formulate diagnoses.
Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:
- A. ethically can look at a friend's chart to see the diagnosis
- B. shares information from a chart to protect a friend
- C. knows that only the Patient's Bill of Rights advocates confidentiality
- D. reads charts only for professional reasons
Correct Answer: D
Rationale: Nurses must access records only for professional reasons (D) to comply with HIPAA. A and B violate confidentiality, and C is incorrect as multiple laws protect privacy.
Which part of the medical record can be used as evidence in court?
- A. the care plan
- B. the medical orders
- C. the entire record
- D. nursing notes
Correct Answer: C
Rationale: The entire record (C) can be used in court, providing a comprehensive view of care. A, B, and D are parts but not the whole.
A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)
- A. Wait until the end of the shift to document
- B. Cover errors with correction fluid, and write in the correct information
- C. Use as many abbreviations as possible to save space
- D. Document objective data, leaving out opinions
- E. The date and time should be included with each entry
Correct Answer: D,E
Rationale: D: Documentation must be objective (e.g., 'grimaced when moving') to avoid bias. E: Including date and time ensures a clear timeline for legal and care continuity. A is incorrect because timely documentation prevents errors. B is incorrect as errors should be corrected with a single line and initials. C is incorrect because only approved abbreviations should be used to avoid confusion.