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)

Wait until the end of the shift to document

Cover errors with correction fluid, and write in the correct information

Use as many abbreviations as possible to save space

Document objective data, leaving out opinions

The date and time should be included with each entry

Answer and Explanation

Correct Answer : D,E

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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Correct Answer is A

Explanation

A. A head-to-toe assessment: A head-to-toe assessment is the most systematic approach to a complete physical exam, ensuring no body system is overlooked.

B. Subjective data collection: While subjective data is part of the process, it is not a structured approach to an entire physical exam.

C. Objective data collection: Objective data is collected during the exam, but the question asks about the approach to organizing the exam, not the data type.

D. Maslow’s Hierarchy of Needs: Maslow’s hierarchy helps prioritize care but is not a method for performing a physical assessment.

A. signs of fluid overload B. symptoms C. data clustering D. urinary retention

Correct Answer is C

Explanation

A. Signs of fluid overload: Fluid overload presents with edema, crackles in lungs, and increased blood pressure, not dry skin and mucous membranes.

B. Symptoms: Symptoms are subjective (e.g., pain, nausea), while the given findings are observable signs.

C. Data clustering: The nurse groups related signs (flushed skin, dry mucous membranes, elevated temperature) to identify a pattern suggesting dehydration or fever.

D. Urinary retention: Urinary retention is associated with bladder distention and reduced urine output, not dry skin and mucous membranes.

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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)

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Naxlex Comprehensive Predictor Exams

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

Correct Answer is A

Explanation

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:

Correct Answer is C

Explanation

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

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

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

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

JCAHO regulates standards of care to:

Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:

Patient health care records are:

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)