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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.
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In which of the following cases should a progress note be written? Select all that apply.
- A. for any nursepatient interaction
- B. when admitting a patient
- C. when receiving a patient postoperatively
- D. when assisting a patient with ADLs
- E. when a procedure is performed
- F. when a patient sends back an untouched dinner tray
Correct Answer: B,C,E
Rationale: Progress notes are required for significant events such as admissions, postoperative care, and procedures, as they reflect critical changes in the patient's condition or care.
A nurse has access to computerized standardized plans of care. After printing one for a patient, what must be done next?
- A. Date it and put it in the patients record.
- B. Sign it and put it in the Kardex.
- C. Individualize it to the specific patient.
- D. Use it as printed, based on common needs.
Correct Answer: C
Rationale: Standardized care plans must be tailored to the patient's unique needs to ensure appropriate and effective care.
A physicians order reads up ad lib. What does this mean in terms of patient activity?
- A. may walk twice a day
- B. may be up as desired
- C. may only go to the bathroom
- D. must remain on bed rest
Correct Answer: B
Rationale: Up ad lib' means the patient may be up and active as desired, without restrictions.
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.