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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.
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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.
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 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.
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.
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.