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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.
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What is the primary purpose of focus charting?
- A. nursing diagnoses
- B. medical problems
- C. patient concerns
- D. expected outcomes
Correct Answer: C
Rationale: Focus charting centers on patient concerns, allowing nurses to document issues and responses systematically.
A patient asks to see his medical record (chart). How would the nurse respond?
- A. I cant let you do that without a doctors order.
- B. Our hospital policy is that you cant do that.
- C. I will get your chart and provide you with privacy to read it.
- D. Why would you want to do that? It will only make you worry.
Correct Answer: C
Rationale: Patients have the right to access their medical records, and the nurse should facilitate this while ensuring privacy.
Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry?
- A. Alice J, RN
- B. A. Jones, RN
- C. Alice Jones
- D. AJRN
Correct Answer: B
Rationale: The standard format for signing documentation is the nurse's initial, last name, and credentials (e.g., A. Jones, RN), ensuring clarity and professionalism.
A nurse organizes patient data using the SOAP format. Which of the following would be recorded under S of this acronym?
- A. patient complaints of pain
- B. patient symptoms
- C. patients chief complaint
- D. patient interventions
Correct Answer: A
Rationale: The 'S' in SOAP stands for subjective data, which includes the patient's complaints, such as pain.
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.