Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Incident reports must be recorded in the nurse's notes

Institutions are only reimbursed for patient care that is documented

Document only when not successful

The patient record is a complete picture of individualized problems, treatments and responses to treatments

Answer and Explanation

Correct Answer : B,D

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

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Correct Answer is A

Explanation

A. Every facility should have an approved abbreviations list. Hospitals and healthcare settings maintain a list of approved abbreviations to ensure consistency and prevent misinterpretation.

B. Creating abbreviations saves time for the person reading the chart: Unapproved abbreviations can lead to confusion and errors, potentially harming the patient.

C. Writing out questionable abbreviations could make a jury think you're hiding something: Avoiding abbreviations improves clarity, and using full words is preferred in legal documentation.

D. Abbreviating drug names and dosages helps reduce medication errors: Abbreviating drug names can cause dangerous medication errors (e.g., MS can mean morphine sulfate or magnesium sulfate). The Joint Commission prohibits certain abbreviations.

A. patient's vital signs are B/P 120/80, P 88 and R 18 B. non-responsive patient C. disoriented patient D. critically patient ill

Correct Answer is A

Explanation

A. Patient’s vital signs are B/P 120/80, P 88, and R 18: Stable, normal vital signs do not indicate an immediate need for a focused assessment unless there is a complaint or concern.

B. Non-responsive patient: A focused neurological and airway assessment is required for an unresponsive patient.

C. Disoriented patient: Disorientation may indicate neurological issues, infection, or metabolic imbalance, requiring a focused mental status and neurological assessment.

D. Critically ill patient: Critically ill patients require frequent focused assessments based on their condition (e.g., respiratory, cardiac, or neurological).

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Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements is correct about abbreviations?

Correct Answer is A

Explanation

A focused assessment should be done by the nurse in all of the following situations EXCEPT:

Correct Answer is A

Explanation

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)

Select the proper order of the phases of the Nursing Process:

Which of the following assists the nurse in the identification of nursing diagnoses?

A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:

When discovering subjective data, recognize that they relate to:

When documenting events in a patient's chart, the nurse should chart:

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as: