Nokea
In which of the following cases should a progress note be written? Select all that apply.
- A. for any nursepatient interaction
- B. when admitting a patient
- C. when receiving a patient postoperatively
- D. when assisting a patient with ADLs
- E. when a procedure is performed
- F. when a patient sends back an untouched dinner tray
Correct Answer: B,C,E
Rationale: Progress notes are required for significant events such as admissions, postoperative care, and procedures, as they reflect critical changes in the patient's condition or care.
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A nurse is documenting information about a patient in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?
- A. PIE system
- B. minimum data set
- C. OASIS
- D. charting by exception
Correct Answer: B
Rationale: The minimum data set is a standardized tool used in Medicare-certified facilities for comprehensive resident assessment and RAI development.
What part of the patients record is commonly used to document specific patient variables, such as vital signs?
- A. progress notes
- B. nursing notes
- C. critical paths
- D. graphic record
Correct Answer: D
Rationale: The graphic record is designed to track measurable variables like vital signs in a clear, visual format.
What is the primary purpose of an incident report?
- A. means of identifying risks
- B. basis for staff evaluation
- C. basis for disciplinary action
- D. format for audiotaped report
Correct Answer: A
Rationale: Incident reports are used to identify risks and improve safety by analyzing events, not for evaluation or discipline.
Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse?
- A. problem-oriented medical record
- B. charting by exception
- C. PIE charting system
- D. focus charting
Correct Answer: B
Rationale: Charting by exception only documents deviations from the norm, which may omit critical details, making it less defensible in court.
A group of nurses visits selected patients individually at the beginning of each shift. What are these procedures called?
- A. nursing care conferences
- B. staff visits
- C. interdisciplinary referrals
- D. nursing care rounds
Correct Answer: D
Rationale: Nursing care rounds involve visiting patients to assess and plan care at the start of a shift.