Who should document care in the patient record?

The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.

The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.

All staff members should document all of the care that they have provided.

All staff should document all care they provided but the RN (as the only independent practitioner) must sign their notes.

Answer and Explanation

The Correct Answer is C

A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.

B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.

C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.

D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.

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Correct Answer is B

Explanation

A. To clarify nursing principles: Nursing orders are action-oriented and not just meant to clarify theoretical principles.

B. To resolve the patient’s problems: Nursing orders focus on patient care interventions that directly address identified problems in the nursing diagnosis.

C. To support physician’s orders: Nursing orders complement medical care but are independent nursing actions, not just support for physician directives.

D. To provide broad, general statements: Nursing orders should be specific, measurable, and actionable, not broad statements.

A. ethically can look at a friend's chart to see the diagnosis B. shares information from a chart to protect a friend C. knows that only the Patient's Bill of Rights advocates confidentiality D. reads charts only for professional reasons

Correct Answer is D

Explanation

A. Ethically can look at a friend's chart to see the diagnosis: Accessing a patient’s chart without a legitimate medical reason violates HIPAA and patient confidentiality laws.

B. Shares information from a chart to protect a friend: Confidentiality applies regardless of personal relationships. Unauthorized sharing of patient information is illegal and unethical.

C. Knows that only the Patient’s Bill of Rights advocates confidentiality: Multiple regulations, including HIPAA, protect patient confidentiality, not just the Patient’s Bill of Rights.

D. Reads charts only for professional reasons: Nurses can only access patient records when directly involved in care. Unnecessary access is a breach of confidentiality.

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Who should document care in the patient record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Clarify the primary purpose of nursing orders:

Correct Answer is B

Explanation

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Correct Answer is D

Explanation

Who should document care in the patient record?

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:

Which of the following statements is correct about abbreviations?

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:

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

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (Select all that apply)

Which of the following is an example of good charting?

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