Chapter 15- Documentation
Review test for chapter 15 in Fundamentals of Nursing by Craven. For massbay students 2012
- 1.
Effective communication is important among healthcare providers because
- A.
It assures care is safe, timely and responsive to client's need
- B.
It eliminates mistakes during client care
- C.
It let's the client know what is going on with his/her own care
Correct Answer
A. It assures care is safe, timely and responsive to client's need -
- 2.
A nurse is caring for six clients on a busy night. She is making rounds to administer drugs. As she administers drugs, when should she document it?
- A.
When she is done administering drugs for all patients, so they don't have to wait
- B.
As soon as she administers the drug, so she won't forget
- C.
Right before administering the drug, so she won't forget
- D.
Before she starts any drug administration in order to save time
Correct Answer
B. As soon as she administers the drug, so she won't forget -
- 3.
A nurse is writing a note. She is writing in black ink to ensure readable photocopies. Another important concept of her note is:
- A.
Be as subjective as possible, because what the client has to say is important
- B.
Be as objective as possible, it is interdisciplinary communication
- C.
Interpret data and record her interpretations, afterall she is well trained
Correct Answer
B. Be as objective as possible, it is interdisciplinary communication -
- 4.
All of the following are purposes of a client record, except:
- A.
Communication, it assure continuity of care
- B.
Assessment, progress is determined
- C.
Reimbursement, for audits
- D.
Research, refines the definition of the nursing practice
- E.
Access, the client's family can easily understand the client's situation
Correct Answer
E. Access, the client's family can easily understand the client's situation -
- 5.
The nurse is looking for a patient's admission records, where can she find it?
- A.
The Kardex
- B.
The MAR
- C.
The patient's medical record
Correct Answer
C. The patient's medical record -
- 6.
The most relevant definition of "source records" is
- A.
They are a source of medication administration
- B.
They divide the body system and prioritize
- C.
They are organized so each discipline has a separate section
Correct Answer
C. They are organized so each discipline has a separate section -
- 7.
As part of JCAHO standards, the nursing assessment should be documented
- A.
Within 8 to 24 hours fo admission
- B.
When the healthcareproviders discover the exact cause of the problem
- C.
Within the first 3 hours of admission
Correct Answer
A. Within 8 to 24 hours fo admission -
- 8.
Each entry or the nurse's recording should begin with
- A.
Dear patient
- B.
Time
- C.
Signature and title
- D.
Dear Dr.
Correct Answer
B. Time -
- 9.
A nurse is writing a note, she knows that all of the following are important data except:
- A.
What she saw
- B.
What she heard
- C.
What she smelled
- D.
What she felt(tactile)
- E.
What she thought
Correct Answer
E. What she thought -
- 10.
A patient says, "i have sharp pains on my arm." the best way to record this as objectively as possible, would be
- A.
To keep the statement in quotations
- B.
Record the patient is complaining of pain level 3
- C.
Record patient seems to be in pain, his arm hurts
Correct Answer
A. To keep the statement in quotationsExplanation
*the question never rated the pain*Rate this question:
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- 11.
A nurse is writing a note and remembers the acronym FACTO which of the following does it stand for
- A.
Fast, abnormalities, care, topical, oral
- B.
Factual, accurate, concise, timely, organized
- C.
First, admission, careplan, treatment, options
Correct Answer
B. Factual, accurate, concise, timely, organized -
- 12.
POC, point of care, documentation promotes all of the following, except
- A.
Efficiency
- B.
Accuracy
- C.
Timeliness
- D.
Opportunity for the nurse to document at a later time
Correct Answer
D. Opportunity for the nurse to document at a later time -
- 13.
A nurse is documenting a note and she chooses the SOAP note method, she chose this because
- A.
All charting focuses on identified problems
- B.
It is for communication among nurses only
- C.
Subjective data is not necessary in this type of note
Correct Answer
A. All charting focuses on identified problems -
- 14.
SOAP stands for: Subjective, Objective, Assessment, Plan
- A.
True
- B.
False
Correct Answer
A. True -
- 15.
A nurse chooses PIE (problem, intervention, evaluation) notes to document, probably because
- A.
She can easily add or eliminate problems, so it is efficient and flexible
- B.
It is multidisciplinary
- C.
It is difficult to audit
Correct Answer
A. She can easily add or eliminate problems, so it is efficient and flexibleExplanation
It is for nurses only. It is easily audited.Rate this question:
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- 16.
After a teaching session, the nurse documents the session most efficiently by using
- A.
DAR note (data, action, response)
- B.
PIE note (Problem, Intervention, Evaluation)
- C.
SBAR (situation, background, assessment, recommendation)
Correct Answer
A. DAR note (data, action, response) -
- 17.
When charting, the nurse used all of the following correctly, except:
- A.
Shared significant info about family
- B.
Gave only essential background info
- C.
Evaluated nursing care
- D.
Used "good" and "bad" when describing the client's condition
Correct Answer
D. Used "good" and "bad" when describing the client's condition -
- 18.
A patient has asked not to be put in the hospital's directory, according to HIPPA's patient rights, this action
- A.
Is to be done as the patient wishes
- B.
Is to be denied to the patient
- C.
Goes by individual cases
Correct Answer
A. Is to be done as the patient wishes -
- 19.
These are all advantages of CBE, charting by exception, except:
- A.
Takes less time for immediate documentation
- B.
Best where routine care is anticipated
- C.
It takes time to develop and maintain
- D.
Changes in patient status are readily detected
Correct Answer
C. It takes time to develop and maintain -
- 20.
Clinical pathways are best used for patients with specific, predictable conditions.
- A.
True
- B.
False
Correct Answer
A. True -
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