Identify the two primary methods used to collect data:

interview and physical examination

review of the doctor's orders and the Kardex

written report by patient and family

review of the chart and the nurse's notes

Answer and Explanation

The Correct Answer is A

A. Interview and physical examination: The two primary methods of data collection in nursing are:

Interview (subjective data: patient history, symptoms, concerns)
Physical examination (objective data: vital signs, assessment findings)

B. Review of the doctor's orders and the Kardex: This provides supplementary data but does not directly collect patient information.

C. Written report by patient and family: This may provide valuable subjective data but is not a primary method of data collection.

D. Review of the chart and the nurse’s notes: This is reviewing existing documentation, not actively collecting data.

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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. Assistive personnel reports the patient walks with a limp B. Patient reports pain level as 3 on a scale of 1 to 10 C. Heart rate 72 beats per minute D. Respiratory rate 22 per minute with even unlabored respirations E. Coughed up 5 mL yellow sputum F. Headache in frontal area

Correct Answer is ["C","D","E"]

Explanation

A. Assistive personnel reports the patient walks with a limp: This is secondhand information (reported by UAP), not directly observed by the nurse.

B. Patient reports pain level as 3 on a scale of 1 to 10: Pain is subjective data because it is based on the patient's self-report.

C. Heart rate 72 beats per minute: Heart rate is measured by the nurse, making it objective data.

D. Respiratory rate 22 per minute with even unlabored respirations: The nurse directly observes and measures respiratory rate, making it objective data.

E. Coughed up 5 mL yellow sputum: The nurse can observe and quantify the sputum (color and volume), making it objective data.

F. Headache in frontal area: A headache is subjective data because only the patient can describe it.

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Identify the two primary methods used to collect data:

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Naxlex Comprehensive Predictor Exams

One benefit of computerized charting is that:

Correct Answer is C

Explanation

The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

Correct Answer is ["C","D","E"]

Explanation

The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:

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

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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:

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

Which of the following is an example of good charting?

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