Exam 7: Documentation of Nursing Care

The nurse explains that should a patient return to the hospital for treatment within _______ years, the medical record can be retrieved from medical records for review.

In a medical record for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse documents "Subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge.” This type of documentation is an example of:

A resident in a skilled nursing facility for a short term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests." When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:

The nurse uses the flow sheet in patient care documentation primarily:

A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:

Which examples of documentation would be most informative to transcribe to the patient's medical record?

The electronic medical record was set up as a goal of the Stimulus Law that President Obama signed in 2009, for the purpose of providing a:

A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: "Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication." This documentation is:

A nurse understands that the primary care provider's directives for patient care are also referred to as the:

A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:

Advantages of source-oriented or narrative charting include all of the following except that it:

Advantages of the problem-oriented medical record (POMR) are that this method of documentation: (Select all that apply.)

The method of computer-assisted charting: (Select all that apply.)

A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:

A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:

Helpful cultural information the nurse should include on the admission note is: (Select all that apply.)

Documentation that follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses' progress notes is _______ charting.

In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) documentation is that charting by exception:

When the nurse documents in narrative or source-oriented format about the patient's condition and the nursing care provided, it is appropriate for him to record:

If an agency is using computer-assisted charting, the nurse is responsible for: