Which of the following statements is correct about abbreviations?

Every facility should have an approved abbreviations list.

Creating abbreviations saves time for the person reading the chart.

Writing out questionable abbreviations could make a jury think you're hiding something

Abbreviating drug name and dosages helps reduce medication errors.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is C

Explanation

A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.

B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.

C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.

D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.

A. a head-to-toe assessment B. subjective data collection C. objective data collection D. Maslow's Hierarchy of Needs E. Coughed up 5 mL yellow sputum

Correct Answer is A

Explanation

A. A head-to-toe assessment: A head-to-toe assessment is the most systematic approach to a complete physical exam, ensuring no body system is overlooked.

B. Subjective data collection: While subjective data is part of the process, it is not a structured approach to an entire physical exam.

C. Objective data collection: Objective data is collected during the exam, but the question asks about the approach to organizing the exam, not the data type.

D. Maslow’s Hierarchy of Needs: Maslow’s hierarchy helps prioritize care but is not a method for performing a physical assessment.

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Which of the following statements is correct about abbreviations?

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

Correct Answer is C

Explanation

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:

Correct Answer is A

Explanation

JCAHO regulates standards of care to:

One benefit of computerized charting is that:

What is the major concern when using a computer for documentation?

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Identify the two primary methods used to collect data:

A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)

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