Nokea
Which of the following data entries follows the recommended guidelines for documenting data?
- A. Patient is overwhelmed by the diagnosis of pancreatic cancer.
- B. Patient kidneys are producing sufficient amount of measured urine.
- C. Following oxygen administration, vital signs returned to baseline.
- D. Patient complained about the quality of the nursing care provided on previous shift.
Correct Answer: C
Rationale: This entry is objective, specific, and focused on measurable outcomes, adhering to documentation guidelines.
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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.
Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse?
- A. problem-oriented medical record
- B. charting by exception
- C. PIE charting system
- D. focus charting
Correct Answer: B
Rationale: Charting by exception only documents deviations from the norm, which may omit critical details, making it less defensible in court.
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 is documenting information about a patient in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?
- A. PIE system
- B. minimum data set
- C. OASIS
- D. charting by exception
Correct Answer: B
Rationale: The minimum data set is a standardized tool used in Medicare-certified facilities for comprehensive resident assessment and RAI development.
What is the primary purpose of an incident report?
- A. means of identifying risks
- B. basis for staff evaluation
- C. basis for disciplinary action
- D. format for audiotaped report
Correct Answer: A
Rationale: Incident reports are used to identify risks and improve safety by analyzing events, not for evaluation or discipline.