Exam 7: Assessment and Documentation for Optimal Care

Using the RAI,the nurse identifies a trigger for a male nursing home resident who requires an indwelling urinary catheter from the MDS.Which should the nurse do next?

The same nursing documentation record is used in every unit of a hospital.Why does a hospital use a standardized form for nursing documentation?

Which option is not a primary reason that documentation is important?

Which one of the following is connected with the nursing home reform mandated by a 1987 law?

The nurse scans an older man's identification band in preparation for medication administration.Which step should the nurse implement next?

An older woman has diabetes mellitus and requires hemodialysis for renal failure.She is discharged to home to recover from a sternal wound infection and coronary artery bypass graft surgery (CABG).A home care nurse will provide wound care.Which of the following is the major justification for the complete and accurate documentation of this older adult's care?

Which mental status assessment tool(s)would be appropriate for use in long-term care facilities?

The OASIS was implemented to provide the format for a comprehensive assessment in the home health care setting.How is this assessment tool used?

Which of the following does the nurse use to categorize the desired end result of nursing care delivered to a patient when using problem-oriented nurses' notes?

The federal government requires the use of a specific standardized documentation tool for home nursing care.Which information must a home nurse add to the approved documentation tool?

Which documentation tool does the nurse use to achieve optimal functional status for a nursing home resident?

The nurse must inform an older adult who does not speak English about patient rights.In addition,the nurse must have the adult sign the document about information access.Which intervention should the nurse use to maintain the confidentiality of this older adult?

What is a SOAP note?

Which of the following is a true statement about documentation?