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 A

Explanation

A. Patient’s vital signs are B/P 120/80, P 88, and R 18: Stable, normal vital signs do not indicate an immediate need for a focused assessment unless there is a complaint or concern.

B. Non-responsive patient: A focused neurological and airway assessment is required for an unresponsive patient.

C. Disoriented patient: Disorientation may indicate neurological issues, infection, or metabolic imbalance, requiring a focused mental status and neurological assessment.

D. Critically ill patient: Critically ill patients require frequent focused assessments based on their condition (e.g., respiratory, cardiac, or neurological).

A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff. B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care. C. All staff members should document all of the care that they have provided. D. All staff should document all care they provided but the RN (as the only independent practitioner) must sign their notes.

Correct Answer is C

Explanation

A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.

B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.

C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.

D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.

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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

A focused assessment should be done by the nurse in all of the following situations EXCEPT:

Correct Answer is A

Explanation

Who should document care in the patient record?

Correct Answer is C

Explanation

On what form/forms should the nurse chart when administering a narcotic?

When discovering subjective data, recognize that they relate to:

To what does objective data refer when assessing a patient?

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

Identify the two primary methods used to collect data:

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:

When using the SOAP method of charting, S stands for subjective data which means:

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