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

the specific time of all sudden changes in the patient's condition

the period the shift covers

every 2 hours

every hour on the hour

Answer and Explanation

The Correct Answer is A

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).

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Correct Answer is A

Explanation

A. Patient provided data: Subjective data includes information the patient states, such as symptoms, pain level, or concerns.

B. All of the answers are correct: Not all answer choices describe subjective data.

C. Observed data: Observations made by the nurse (e.g., swelling, pallor) are objective, not subjective.

D. Measured data: Measurable data, such as vital signs, are objective, not subjective.

A. Wait until the end of the shift to document B. Cover errors with correction fluid, and write in the correct information C. Use as many abbreviations as possible to save space D. Document objective data, leaving out opinions E. The date and time should be included with each entry

Correct Answer is ["D","E"]

Explanation

A. Wait until the end of the shift to document: Documentation should be done promptly after care is provided to ensure accuracy and completeness. Delaying documentation increases the risk of errors or omissions.

B. Cover errors with correction fluid, and write in the correct information: Errors should never be covered with correction fluid. Instead, a single line should be drawn through the mistake, followed by the correction and the nurse’s initials.

C. Use as many abbreviations as possible to save space: Only approved abbreviations should be used to avoid misinterpretation and increase clarity. Overuse of abbreviations can lead to confusion.

D. Document objective data, leaving out opinions: Documentation should be factual and objective (e.g., "Patient grimaced when moving" instead of "Patient appears to be in pain"). Subjective or opinion-based language should be avoided.

E. The date and time should be included with each entry: Every entry must have a date and time to provide an accurate timeline of care, ensuring legal protection and continuity of care.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When using the SOAP method of charting, S stands for subjective data which means:

Correct Answer is A

Explanation

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)

Correct Answer is ["D","E"]

Explanation

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The primary source of assessment information is: