In which of the following locations on a paper health record should a medical assistant document a patient's temperature, pulse, and respirations?
Subjective
Objective
Assessment
Plan
The Correct Answer is B
A. Subjective: The subjective section contains information reported by the patient, such as symptoms and experiences, not objective measurements.
B. Objective: Objective measurements, such as vital signs (temperature, pulse, respirations), are documented in the objective section of the health record because they are measurable and observable data.
C. Assessment: The assessment section includes the healthcare provider’s interpretation of the data and diagnosis, not the actual measurements.
D. Plan: The plan section details the proposed treatment or management strategy, not the recorded measurements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Safety data sheet (SDS): SDS provides information on handling and disposing of hazardous materials, not specifically on infection control or disease prevention.
B. Standard precautions: Standard precautions are infection control practices used to prevent the spread of disease in healthcare settings, such as hand hygiene and using personal protective equipment.
C. CLIA: CLIA (Clinical Laboratory Improvement Amendments) regulates laboratory testing but does not specifically address disease prevention in patient interactions.
D. Exposure plan: An exposure plan is related to handling and reporting exposure to bloodborne pathogens, not general disease prevention.
Correct Answer is C
Explanation
A. Colonoscopy: A colonoscopy is an invasive procedure that requires written informed consent due to the associated risks and the need for detailed patient understanding.
B. Dilation and curettage: Dilation and curettage (D&C) is an invasive procedure requiring written informed consent, including an explanation of risks, benefits, and alternatives.
C. Venipuncture: For venipuncture, verbal consent is generally sufficient, as it is a minor procedure with minimal risk.
D. Cardiac stress test: A cardiac stress test, while less invasive, typically requires written informed consent due to potential risks and the need for patient understanding.
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