Nokea
On what form/forms should the nurse chart when administering a narcotic?
- A. Physician's Order Sheet
- B. Narcotic Administration Sheet
- C. Care Plan
- D. MAR and Narcotic Administration Sheet
Correct Answer: D
Rationale: Narcotics are documented on both the MAR (Medication Administration Record) (D) for all medications and the Narcotic Administration Sheet for controlled substances to ensure tracking and compliance. A, B alone, and C are incorrect.
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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.
When discovering subjective data, recognize that they relate to:
- A. signs
- B. objective cues
- C. symptoms
- D. observable data
Correct Answer: C
Rationale: Subjective data relates to symptoms (C) reported by the patient, like pain or nausea. Signs (A), objective cues (B), and observable data (D) are objective, measurable findings.
Who should document care in the patient record?
- A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.
- B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.
- C. All staff members should document all of the care that they have provided.
- D. All staff should document all care they provided but the RN (as the only independent practitioner) must sign their notes.
Correct Answer: C
Rationale: All staff (C) must document their own care for accuracy and accountability. A, B, and D incorrectly assign documentation responsibilities.
Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)
- A. Incident reports must be recorded in the nurse's notes
- B. Institutions are only reimbursed for patient care that is documented
- C. Document only when not successful
- D. The patient record is a complete picture of individualized problems, treatments and responses to treatments
Correct Answer: B,D
Rationale: B: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as it proves care was provided. D: The patient record provides a comprehensive view of the patient's problems, treatments, and responses, ensuring continuity of care. A is incorrect because incident reports are separate from the medical record to maintain patient safety internally. C is incorrect because documentation should include both successful and unsuccessful interventions for completeness.
Which of the following is an example of good charting?
- A. No complaints of pain or discomfort.'
- B. The patient states, 'It feels like a knife stabbing me.'
- C. Lump diminished.'
- D. Patient's condition much better today than yesterday.'
Correct Answer: B
Rationale: Quoting the patient's exact words (B) is precise and clear. A lacks verification, C is vague, and D lacks measurable detail.