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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.
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Which of the following abbreviations are on the Joint Commission do not use abbreviations? Select all that apply.
- A. U (unit)
- B. QD (daily)
- C. NPO (nothing per os)
- D. mL (milliliters)
- E. > (greater than)
- F. mcg (micrograms)
Correct Answer: A,B,E
Rationale: The Joint Commission prohibits abbreviations like U, QD, and > due to their potential for misinterpretation, which can lead to medication errors.
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.
A nurse is documenting the intensity of a patients pain. What would be the most accurate entry?
- A. Patient complaining of severe pain.
- B. Patient appears to be in a lot of pain and is crying.
- C. Patient states has pain; walking in hall with ease.
- D. Patient states pain is a 9 on a scale of 1 to 10.
Correct Answer: D
Rationale: Using a standardized pain scale, such as 1 to 10, provides a precise and measurable documentation of the patient's pain intensity, making it the most accurate entry.
A nurse uses informatics to plan nursing care for a patient. Which three terms best describes this science as it is applied to nursing?
- A. data, information, knowledge
- B. process, documentation, analysis
- C. research, controls, variables
- D. hypothesis, nursing, practice
Correct Answer: A
Rationale: Nursing informatics involves transforming data into information and knowledge to support patient care.
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.