Indicate whether the following statements are True (T) or Fa...

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.

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Guidelines for paper documentation include which of the following?

A. All documentation for your shift must be signed after you have charted your last entry for the shift.
B. All documentation must be done in cursive writing.
C. Charting should be done in blocks of time to reduce the number of unnecessary entries.
D. The date and time should be included with each entry.

Correct Answer: A,D

Rationale: Paper documentation requires signing at shift's end (A) and including date/time (D). Cursive is not mandatory (B), and block charting (C) is not standard.

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. The correct signature for documentation includes which of the following?

A. First and last names
B. First name, last initial, and credentials
C. First initial, middle initial, last initial, and credentials
D. First name, middle name, and last name
E. First initial, last name, and credentials

Correct Answer: A,E

Rationale: Correct signatures include first and last names (A) or first initial, last name, and credentials (E). B, C, and D do not meet standard documentation requirements.

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.

Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills - DOCUMENTATION Related

Correct Answer: B