Nokea
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.
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What is the nurses best defense if a patient alleges nursing negligence?
- A. testimony of other nurses
- B. testimony of expert witnesses
- C. patients record
- D. patients family
Correct Answer: C
Rationale: The patient's record is the most objective and reliable evidence of the care provided, serving as the nurse's best defense against allegations of negligence.
Which of the following information would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply.
- A. patient sex
- B. patient admission date
- C. patient physical assessment
- D. patient insurance
- E. patient history
- F. patient ethnicity
Correct Answer: A,B,D,F
Rationale: The minimum data set includes demographic and administrative data like sex, admission date, insurance, and ethnicity to ensure standardized reporting.
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.
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.
Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry?
- A. Alice J, RN
- B. A. Jones, RN
- C. Alice Jones
- D. AJRN
Correct Answer: B
Rationale: The standard format for signing documentation is the nurse's initial, last name, and credentials (e.g., A. Jones, RN), ensuring clarity and professionalism.