The primary source of assessment information is:

the patient's friends

past medical records

the patient's record

the patient

Answer and Explanation

The Correct Answer is D

A. The patient's friends: While family and friends can provide secondary information, they are not the primary source of assessment data.

B. Past medical records: Past records can provide valuable history, but they do not replace real-time data from the patient.

C. The patient's record: The medical record is a collection of past documentation but is not a source of new assessment data.

D. The patient: The patient is the primary source of assessment data, as they provide information about their symptoms, medical history, and concerns.

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Correct Answer is A

Explanation

A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.

B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.

C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.

D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).

A. use a Nursing Diagnosis from a source other than NANDA-I B. limit the number of interventions C. select interventions which will be easy to implement D. involve the patient in the process

Correct Answer is D

Explanation

A. Use a Nursing Diagnosis from a source other than NANDA-I: NANDA-I provides standardized nursing diagnoses that ensure accurate problem identification and care planning.

B. Limit the number of interventions: Interventions should be appropriate and sufficient rather than arbitrarily limited.

C. Select interventions which will be easy to implement: Interventions should be effective and individualized, not just easy.

D. Involve the patient in the process: Patient involvement ensures better adherence, understanding, and personalized care.

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The primary source of assessment information is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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:

Correct Answer is D

Explanation

JCAHO regulates standards of care to:

Which of the following statements is correct about abbreviations?

Clarify the primary purpose of nursing orders:

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

What is the major concern when using a computer for documentation?

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

A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)