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When documenting events in a patient's chart, the nurse should chart:
- A. the specific time of all sudden changes in the patient's condition
- B. the period the shift covers
- C. every 2 hours
- D. every hour on the hour
Correct Answer: A
Rationale: Charting sudden changes with specific times (A) ensures accuracy and supports care decisions. B, C, and D are less precise or unnecessary.
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Select the type of assessment which is performed continuously throughout nurse-patient contact:
- A. focused
- B. body systems
- C. subjective
- D. complete
Correct Answer: A
Rationale: Focused assessments (A) are ongoing, targeting specific issues like pain or breathing during contact. Body systems (B), subjective (C), and complete (D) assessments are not continuous.
Patient provided subjective data of intermittent chest pain upon exertion
Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:
- A. a head-to-toe assessment
- B. subjective data collection
- C. objective data collection
- D. Maslow's Hierarchy of Needs
Correct Answer: A
Rationale: A head-to-toe assessment (A) organizes a complete exam systematically. B and C are data types, not approaches, and D prioritizes needs, not physical exams.
When using the SOAP method of charting, S stands for subjective data which means:
- A. patient provided data
- B. all of the answers are correct
- C. observed data
- D. measured data
Correct Answer: A
Rationale: Subjective data (A) includes patient-reported information like pain or symptoms. Observed (C) and measured (D) data are objective, and B is incorrect as only A is accurate.
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.
Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:
- A. CNA
- B. Technician
- C. RN
- D. LPN/LVN
Correct Answer: C
Rationale: The RN (C) is responsible for analyzing data and formulating nursing diagnoses, as it requires critical thinking within their scope of practice. CNAs (A) and Technicians (B) assist with care but do not diagnose. LPNs/LVNs (D) collect data but do not formulate diagnoses.