Nokea
Which document would be found in the Advanced Directive section of a source-oriented medical record?
- A. Signed surgical consent
- B. Living will
- C. Discharge plans
- D. Treatment plan for the diagnosis
Correct Answer: B
Rationale: The Advance Directive section contains documents like living wills, which outline patient preferences for care.
You may also like to solve these questions
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 of the following times during a 7 a.m. to 7 p.m. shift would be appropriate to document on a patient's chart?
- A. As soon as possible after an occurrence or event
- B. Once at the beginning of the shift, again about midway through the shift, and the last time at the end of the shift
- C. Before the physician makes morning rounds at 10:15 a.m.
- D. Following the performance of physical assessments
- E. Not until all your patient care has been completed for the shift
- F. At least every 2 hours
Correct Answer: A
Rationale: Documentation should occur as soon as possible after an event to ensure accuracy and timeliness.
When you use an EHR, you may enter information in which of the following ways?
- A. Hand-held computer
- B. Computer at a computer station in the hallway
- C. Computer at the nurses' station
- D. Bedside terminal in the patient's room
- E. Your personal laptop wherever it is convenient
Correct Answer: A, B, C, D
Rationale: EHRs can be accessed via authorized devices like hand-held computers, hallway stations, nurses' stations, or bedside terminals, but personal laptops are not secure.
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.