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What type of documentation would you, as a nurse, be responsible for performing in the section marked Physician's Orders?
- A. The patient's plan of care to be followed
- B. The vital signs taken during your shift along with the I&O totals
- C. Transcription date, time, and your initials
- D. When you noted the orders
- E. Verbal order given to you by the physician
- F. Nursing orders
Correct Answer: C, D, E
Rationale: Nurses document transcription details, noting of orders, and verbal orders in the Physician's Orders section.
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When working in long-term care, the nurse is required to document assessment data on a resident how often?
- A. Every 2 hours
- B. Every 24 hours
- C. Every week
- D. Every month
Correct Answer: D
Rationale: In long-term care, resident assessments are typically documented monthly unless otherwise specified.
In a source-oriented medical record, which of these would be found in the Nurse's Notes section?
- A. Nurse's assessment data
- B. HCP's assessment data
- C. Patient's response to initiation of IV therapy
- D. Patient's living will
- E. Report of chest x-ray results
- F. Patient's complains of incisional pain
Correct Answer: A, C, F
Rationale: Nurse's Notes include nurse assessments, patient responses, and patient complaints, not HCP data, living wills, or diagnostic reports.
Which setting(s) may use Kardexes and paper charts?
- A. Inpatient hospitals
- B. Outpatient surgery centers
- C. Home health care
- D. Long-term care
Correct Answer: A, B, C, D
Rationale: Kardexes and paper charts may be used in various settings, including hospitals, surgery centers, home health, and long-term care.
Which of the following phrases are written objectively?
- A. Ate 45% full-liquid diet. Did not act very hungry and acted like she should not have drunk all that she did.'
- B. Complaining of really severe pain and wants something for it.'
- C. Ambulated unassisted the length of hallway without complaints of fatigue or shortness of breath.'
- D. Does not feel good today. Angry and depressed.'
- E. Makes good eye contact, smiling. States feels 'much better today than yesterday.'
Correct Answer: C, E
Rationale: Objective phrases describe observable facts, like ambulation or specific patient statements, without subjective interpretation.
Which of the following entries are good examples of succinct charting?
- A. Bed bath was given and teeth brushed. Hair was shampooed and tangles combed out. Soaked fingernails in warm soapy water for 20 minutes, then filed them and cleaned them using an orange stick. Legs were shaved and lotion applied to all pressure points and areas of dry skin. Gave her a back rub.'
- B. Sacral wound measures 2 x 4 cm with 1-cm depth. Wound bed pale and dry, with 1-cm black eschar center circumferenced by 0.5-cm dark erythema. No granulation noted. Moderate amount foul-smelling green purulent drainage.'
- C. Patient is having moderate amount of cramping in her abdomen. It seems to be from her uterus. When I inquired, the patient said it is time for her to start her menses. The patient also said she usually does not experience premenstrual cramping.'
- D. BP - 124/72, T - 98.8°F orally, P - 64 strong & reg, R - 17 reg & even.'
Correct Answer: B, D
Rationale: Succinct charting is specific and concise, like wound measurements or vital signs, avoiding unnecessary detail.