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

patient's nursing problem

interventions carried out to meet the patient's needs

patient's medical problem

the patient's response to the intervention carried out

Answer and Explanation

The Correct Answer is B

A. Patient's nursing problem: Nursing problems are identified in assessments, not the actual care documentation.

B. Interventions carried out to meet the patient’s needs: Documentation should include interventions, the time they were performed, and the caregiver’s signature for legal and professional accountability.

C. Patient’s medical problem: Medical problems are diagnosed by physicians, while nurses document care interventions related to nursing diagnoses.

D. The patient's response to the intervention carried out: While patient responses should be documented, this question focuses on recording interventions, not patient reactions.

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Correct Answer is C

Explanation

A. It increases cost.: While initial implementation is costly, computerized charting ultimately reduces costs by improving efficiency and reducing errors.

B. It promotes individualization of the medical record.: Computerized systems standardize documentation rather than individualizing it. However, personalization can be added through specific notes.

C. It improves legibility.: Handwritten notes can be illegible, leading to errors. Computerized charting eliminates handwriting issues and ensures clarity.

D. It minimizes the number of forms to be completed.: While it may reduce paperwork, it does not necessarily minimize documentation, as structured data entry is still required.

A. the care plan B. the medical orders C. the entire record D. nursing notes

Correct Answer is C

Explanation

A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.

B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.

C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.

D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

One benefit of computerized charting is that:

Correct Answer is C

Explanation

Which part of the medical record can be used as evidence in court?

Correct Answer is C

Explanation

Select the proper order of the phases of the Nursing Process:

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?

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:

In which step of the nursing process do nurses look at outcomes?

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

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

The primary source of assessment information is: