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

Incident reports must be recorded in the nurse's notes

Institutions are only reimbursed for patient care that is documented

Document only when not successful

The patient record is a complete picture of individualized problems, treatments and responses to treatments

Answer and Explanation

Correct Answer : B,D

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.

B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.

C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.

D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).

A. Every facility should have an approved abbreviations list. B. Creating abbreviations saves time for the person reading the chart. C. Writing out questionable abbreviations could make a jury think you're hiding something D. Abbreviating drug name and dosages helps reduce medication errors.

Correct Answer is A

Explanation

A. Every facility should have an approved abbreviations list. Hospitals and healthcare settings maintain a list of approved abbreviations to ensure consistency and prevent misinterpretation.

B. Creating abbreviations saves time for the person reading the chart: Unapproved abbreviations can lead to confusion and errors, potentially harming the patient.

C. Writing out questionable abbreviations could make a jury think you're hiding something: Avoiding abbreviations improves clarity, and using full words is preferred in legal documentation.

D. Abbreviating drug names and dosages helps reduce medication errors: Abbreviating drug names can cause dangerous medication errors (e.g., MS can mean morphine sulfate or magnesium sulfate). The Joint Commission prohibits certain abbreviations.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

Which of the following statements is correct about abbreviations?

Correct Answer is A

Explanation

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

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

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)

Select the type of assessment which is performed continuously throughout nurse-patient contact:

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:

Identify the two primary methods used to collect data:

The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date it is determined that a/an:

JCAHO regulates standards of care to: