Nokea
Indicate whether the following statements are True (T) or False (F). An advantage of computerized documentation is that it is easy to read.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Computerized documentation is typically legible, reducing errors from handwriting.
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Indicate whether the following statements are True (T) or False (F). In charting by exception, normal findings are not charted and checklists are used for routine care.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Charting by exception focuses on abnormal findings, using checklists for routine care.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following would be subjective data?
- A. Pain
- B. Itching
- C. Grimacing
- D. Flushing
- E. 124/74
- F. WBC-13,200
- G. Sleeping
Correct Answer: A,B
Rationale: Subjective data is reported by the patient, such as pain (A) or fatigue itching (B). Grimacing (C), flushing (D), blood pressure (E), WBC count (F), and sleeping (G), and snoring (H) are objective, as they can be observed or measured.
Indicate whether the following statements are True (T) or False (F). A federal law known as OBRA mandates that an extensive assessment form called the MDS must be completed on every patient admitted to the hospital.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False (F): OBRA mandates the MDS for long-term care facilities, not hospitals.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following is(are) a purpose of documentation?
- A. To provide a record for administration to prove that the nurses have earned their pay
- B. To provide a permanent record of medical diagnoses, nursing diagnoses, plan of care, care provided, and the patient's response to that care
- C. To serve as a punitive measure for nurses who will not do all the interventions
- D. To serve as a record of accountability for quality assurance, accreditation, and reimbursement purposes
Correct Answer: B,D
Rationale: Documentation serves as a permanent record of patient care (B) and supports accountability for quality assurance, accreditation, and reimbursement (D). A is incorrect as documentation is not about proving nurses' pay, and C is incorrect as it is not a punitive measure.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
- A. Charting in code
- B. Logging off
- C. Charting in privacy
- D. Signing on with a password
Correct Answer: B
Rationale: Logging off (B) prevents unauthorized access and alterations. Charting in code (A) is not standard, privacy (C) is important but not preventive, and passwords (D) are for access, not alteration prevention.