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

the specific time of all sudden changes in the patient's condition

the period the shift covers

every 2 hours

every hour on the hour

Answer and Explanation

The Correct Answer is A

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).

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Correct Answer is D

Explanation

A. Oxygen will be continued: Continuing oxygen therapy is an intervention, not a measurable outcome.

B. The patient's coughing frequency will increase: While coughing can help clear secretions, increased coughing does not necessarily indicate improved airway clearance.

C. Cyanosis may be present: Cyanosis is a sign of worsening oxygenation, not an improved outcome.

D. Within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea: A desired outcome should be specific, measurable, and indicate improvement. The resolution of dyspnea demonstrates effective airway clearance.

A. not used by anyone else but the direct care providers B. concise, legal records of all care given and responses C. owned by the patient, who has a right to see the data any time he/she wishes D. confidential information and cannot be taken to court

Correct Answer is B

Explanation

A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.

B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.

C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.

D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

Patient health care records are:

Correct Answer is B

Explanation

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

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

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:

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

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:

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

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

Clarify the primary purpose of nursing orders: