Question 1

The nurse charts only additional treatments done,changes in patient condition,and new concerns.What is this system of documentation?

Accepted Answer

A) SOAP 
B) Block 
C) CBE 
D) Focus 
A) SOAP 
B) Block 
C) CBE 
D) Focus C

Question 2

What makes home health care documentation unique?

Accepted Answer

A) Some charting is retained at the hospital. 
B) The health care provider's office needs separate charting. 
C) Different health care providers need access. 
D) The health care provider is the pivotal person in the charting. 
A) Some charting is retained at the hospital. 
B) The health care provider's office needs separate charting. 
C) Different health care providers need access. 
D) The health care provider is the pivotal person in the charting. C

Question 3

What will the nurse implement when an error is made when documenting in a patient's chart?

Accepted Answer

A) Scratch out the error. 
B) Apply correction fluid. 
C) Erase the error completely. 
D) Draw a single line through the error. 
A) Scratch out the error. 
B) Apply correction fluid. 
C) Erase the error completely. 
D) Draw a single line through the error. D

Question 4

What form explains the lapse when events are not consistent with facility or national standards of expected care?

Accepted Answer

A) Subjective data 
B) Focus chart 
C) Incident report 
D) Nursing assessment 
A) Subjective data 
B) Focus chart 
C) Incident report 
D) Nursing assessment

Question 5

What does the nurse use as a basis for documentation in focus charting?

Accepted Answer

A) Problem list 
B) Nursing orders 
C) Patient problems 
D) Evaluation 
A) Problem list 
B) Nursing orders 
C) Patient problems 
D) Evaluation

Question 6

What is the process used to appraise the practice of an individual nurse known as?

Accepted Answer

A) Quality assurance 
B) Incident reporting 
C) OBRA 
D) Peer review 
A) Quality assurance 
B) Incident reporting 
C) OBRA 
D) Peer review

Question 7

When documenting an incident in the nurse's notes,what should the nurse include? (Select all that apply.)

Accepted Answer

A) Description of injury,including diagrams of injury placement 
B) Date,time,and location of incident 
C) Name of health care provider and family members notified 
D) Chronologic order of events of the incident 
E) Confirmation that an incident report was initiated 
A) Description of injury,including diagrams of injury placement 
B) Date,time,and location of incident 
C) Name of health care provider and family members notified 
D) Chronologic order of events of the incident 
E) Confirmation that an incident report was initiated

Question 8

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type.This is known as a:

Accepted Answer

A) nursing order. 
B) Kardex. 
C) nursing care plan. 
D) critical pathway. 
A) nursing order. 
B) Kardex. 
C) nursing care plan. 
D) critical pathway.

Question 9

Documentation is necessary for the evaluation of patient care.Of which phase of the nursing process is this an integral part?

Accepted Answer

A) Assessment 
B) Planning 
C) Implementation 
D) Evaluation 
A) Assessment 
B) Planning 
C) Implementation 
D) Evaluation

Question 10

Who is the legal owner of the patient's medical record?

Accepted Answer

A) Patient 
B) Health care provider 
C) Institution 
D) State 
A) Patient 
B) Health care provider 
C) Institution 
D) State

Question 11

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?

Accepted Answer

A) Provide information only to another nurse. 
B) Provide information only to an attorney. 
C) Share information only with the family. 
D) Have a clinical reason for reading the record. 
A) Provide information only to another nurse. 
B) Provide information only to an attorney. 
C) Share information only with the family. 
D) Have a clinical reason for reading the record.

Question 12

When using electronic (or computerized)documentation,which process should the nurse use to ensure that no one alters the information the nurse has entered?

Accepted Answer

A) Charting in code 
B) Logging off 
C) Charting in privacy 
D) Signing on with a password 
A) Charting in code 
B) Logging off 
C) Charting in privacy 
D) Signing on with a password

Question 13

A nurse is receiving a telephone order from a health care provider.The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals.What is the second step of this method?

Accepted Answer

A) Read back 
B) Background 
C) Recommendation 
D) Situation 
E) Assessment 
A) Read back 
B) Background 
C) Recommendation 
D) Situation 
E) Assessment

Question 14

What should the nurse be sure to do when documenting in a patient's chart?

Accepted Answer

A) Include speculation. 
B) Chart consecutively. 
C) Leave blank spaces. 
D) Include retaliatory comments. 
A) Include speculation. 
B) Chart consecutively. 
C) Leave blank spaces. 
D) Include retaliatory comments.

Question 15

Twenty-four-hour charting is designed to establish __________ levels to help determine staffing needs.

Accepted Answer

acuity
Patient acuity,which is

Question 16

The best defense against malpractice claims associated with nursing care is accurate _____________.

Accepted Answer

documentation
Accurate documen

Question 17

Documentation using the DARE format (Data,Action,Response,Education)includes elements of the __________ charting system.

Accepted Answer

focused
Focused char

Question 18

What are some problems associated with electronic (or computerized)charting? (Select all that apply.)

Accepted Answer

A) Security 
B) Expense of training staff 
C) Legibility 
D) Easy retrieval 
E) New terminology 
A) Security 
B) Expense of training staff 
C) Legibility 
D) Easy retrieval 
E) New terminology

Question 19

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____________ ________________.

Accepted Answer

quality assurance
quality assessment
qua

Question 20

What is the purpose of QA (quality assurance)?

Accepted Answer

A) To screen employment applications 
B) To evaluate care results against accepted standards 
C) To conduct in-services for "quality documentation" 
D) To report deviation from standards to the state health department 
A) To screen employment applications 
B) To evaluate care results against accepted standards 
C) To conduct in-services for "quality documentation" 
D) To report deviation from standards to the state health department

Exam 3: Documentation

The nurse charts only additional treatments done,changes in patient condition,and new concerns.What is this system of documentation?

What makes home health care documentation unique?

What will the nurse implement when an error is made when documenting in a patient's chart?

What form explains the lapse when events are not consistent with facility or national standards of expected care?

What does the nurse use as a basis for documentation in focus charting?

What is the process used to appraise the practice of an individual nurse known as?

When documenting an incident in the nurse's notes,what should the nurse include? (Select all that apply.)

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type.This is known as a:

Documentation is necessary for the evaluation of patient care.Of which phase of the nursing process is this an integral part?

Who is the legal owner of the patient's medical record?

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?

When using electronic (or computerized)documentation,which process should the nurse use to ensure that no one alters the information the nurse has entered?

A nurse is receiving a telephone order from a health care provider.The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals.What is the second step of this method?

What should the nurse be sure to do when documenting in a patient's chart?

Twenty-four-hour charting is designed to establish __________ levels to help determine staffing needs.

The best defense against malpractice claims associated with nursing care is accurate _____________.

Documentation using the DARE format (Data,Action,Response,Education)includes elements of the __________ charting system.

What are some problems associated with electronic (or computerized)charting? (Select all that apply.)

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____________ ________________.

What is the purpose of QA (quality assurance)?

The Evolution of Nursing

Legal and Ethical Aspects of Nursing

Communication

Nursing Process and Critical Thinking

Cultural and Ethnic Considerations

Asepsis and Infection Control

Body Mechanics and Patient Mobility

Hygiene and Care of the Patients Environment

Safety

Admission,transfer,and Discharge

Vital Signs

Physical Assessment

Oxygenation

Elimination and Gastric Intubation

Care of Patients Experiencing Urgent Alterations in Health

Dosage Calculation and Medication Administration

Fluids and Electrolytes

Nutritional Concepts and Related Therapies

Complementary and Alternative Therapies

Pain Management,comfort,rest,and Sleep

Surgical Wound Care

Specimen Collection and Diagnostic Testing

Lifespan Development

Loss,grief,dying,and Death

Health Promotion and Pregnancy

Labor and Delivery

Care of the Mother and Newborn

Care of the High-Risk Mother, newborn, and Family With Special Needs

Health Promotion for the Infant, child, and Adolescent

Basic Pediatric Nursing Care

Care of the Child With a Physical and Mental or Cognitive Disorder

Health Promotion and Care of the Older Adult

Concepts of Mental Health

Care of the Patient With a Psychiatric Disorder

Care of the Patient With an Addictive Personality

Home Health Nursing

Long-Term Care

Rehabilitation Nursing

Hospice Care

Professional Roles and Leadership

Filters

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____.