Who should document care in the patient record?

The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.

The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.

All staff members should document all of the care that they have provided.

All staff should document all care they provided but the RN (as the only independent practitioner) must sign their notes.

Answer and Explanation

The Correct Answer is C

A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.

B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.

C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.

D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.

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Correct Answer is A

Explanation

A. Evaluation: Evaluation is the phase where nurses assess whether patient goals and expected outcomes were met.

B. Assessment: Assessment is the first step, where data is collected to identify patient needs.

C. Implementation: Implementation involves carrying out nursing interventions, not reviewing outcomes.

D. Planning: Planning is where goals and interventions are developed, not evaluated.

A. the insulin was administered based per the nurse's testimony B. none of the answers are correct C. the insulin was administered based on the witness testimony D. the insulin was not administered because it was not charted

Correct Answer is D

Explanation

A. The insulin was administered per the nurse's testimony: In legal cases, verbal testimony alone is not sufficient without documentation.

B. None of the answers are correct: One of the answers is correct based on legal documentation principles.

C. The insulin was administered based on the witness testimony: Even though there were witnesses, medication administration must be documented for legal and clinical accountability.

D. The insulin was not administered because it was not charted: "If it wasn't documented, it wasn't done." In legal and medical practice, lack of documentation means the action cannot be verified as completed.

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Who should document care in the patient record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In which step of the nursing process do nurses look at outcomes?

Correct Answer is A

Explanation

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

Correct Answer is D

Explanation

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

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

Which of the following is an example of good charting?

A focused assessment should be done by the nurse in all of the following situations EXCEPT:

Patient health care records are:

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:

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

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