Take this test to see how chart-smart you are.
1. A 68-year-old patient was just admitted to your unit. She's tired and wants to know why she has to answer so many questions. You explain to her that obtaining and documenting her health history is necessary because
a. it's a state-mandated requirement.
b. it's a mode of communication.
c. the nurse-manager told you to do it.
d. the primary care provider wants it done.
2. A 65-year-old patient is admitted to your unit with an exacerbation of chronic obstructive pulmonary disease. After he's settled into bed, you begin asking about his health history. Which of the following should you include in a health history?
a. medical diagnosis
b. the patient's cultural information
c. your best advice on his illness
d. your opinion of his chief complaint
3. A 72-year-old patient is admitted to your unit with a fever of unknown origin. You complete the health history and the admission physical assessment. From this data, you begin making your nursing diagnosis. Which components should you include?
a. human response or problem
b. medical diagnosis
c. expected outcome
4. The nurse caring for your patient on the previous shift identifiedimpaired physical mobilityas a nursing diagnosis for the patient. One of the expected outcomes states, "The patient will ambulate unassisted by 6/12/08." Which element of the outcome hasn't been included?
5. You need to develop a medication teaching plan for a patient with angina and type 2 diabetes. You must include instructions about when to take each medication. Which type of learning outcome is required for this patient?
a. cognitive domain
b. affective domain
c. psychomotor domain
d. effective domain
6. During an admission assessment, the patient states that she enjoys reading. You observe numerous books and magazines at her bedside. Based on this information, which type of learning materials is most appropriate for her?
b. brochures and pamphlets
d. closed-circuit television
7. You're developing a teaching plan for a patient with coronary artery disease. Which learning outcome is in the psychomotor domain?
a. The patient will state when to take each prescribed medication.
b. The patient will demonstrate willingness to comply with lifestyle changes.
c. The patient will demonstrate how to measure his heart rate.
d. The patient will describe the symptoms of heart failure.
8. A 45-year-old patient comes to the short-procedure unit for a hernia repair; his stay is uneventful. Which charting method is best for him?
b. problem-oriented medical record (POMR)
c. Focus charting
d. charting by exception (CBE)
9. When using narrative charting, you document the following statements for a patient who recently underwent exploratory abdominal surgery: Pt. states that incisional pain is unrelieved 30 min. after administration of analgesic. He's grimacing and holding his incision site.This documented observation is an example of
a. a change in the patient's condition.
b. the patient's response to teaching.
c. a lack of improvement in the patient's condition.
d. the patient's response to a treatment or medication.
10. A 52-year-old patient was admitted 3 days ago with acute myocardial infarction. One of the problems on her POMR problem list has been resolved. This should be indicated by
a. assigning a different number to the problem.
b. placing the problem at the bottom of the list.
c. retiring the problem number.
d. using that number for a different problem.
11. A patient underwent colon resection 2 days ago. During his dressing change, you notice an increase in serosanguineous drainage from his incision. Because this is a deviation from written guidelines, you document this observation on the nursing flow sheet. This type of charting system is called
b. problem-intervention-evaluation (PIE).
12. You've been teaching a patient with recently diagnosed diabetes about monitoring his blood glucose. To document this in the progress notes, you record the data, action, and evaluation of his response to the teaching. This type of charting format is called
13. A 29-year-old patient is admitted to your unit after sustaining a femur fracture in a car crash. You're doing your admission assessment and compiling the data on a form that contains a checklist. Which type of form are you using?
14. Because of your patient's deteriorating condition, you couldn't complete the admission database form. You report this information at change of shift. The Joint Commission requires an initial admission assessment to be completed within how many hours after admission?
a. 8 hours
b. 12 hours
c. 24 hours
d. 48 hours
15. You withhold your patient's blood pressure medication because his blood pressure is below the specified parameters needed to administer it. You circle the omitted dose on the medication administration record (MAR), but there's no space to document why you withheld the dose, so you must also document this information
a. on the graphic form.
b. in the patient care flip-over file.
c. in the care plan.
d. in the progress notes.
16. Your patient has an oral temperature of 103.2[degrees] F (39.6[degrees] C). You document this finding on the graphic flow sheet. Which other step is necessary?
a. Document this finding on the patient care flip-over file.
b. Document this finding and your interventions in narrative form in the progress notes.
c. None. You need to document only on the graphic flow sheet.
d. Document this finding in the care plan.
17. A patient needs to be assessed for his ability to perform activities of daily living (ADLs). Which assessment tool helps evaluate six basic ADLs?
a. Katz index
b. Lawton scale
c. Barthel index and scale
d. Conner's rating scale
18. You're concerned about your patient's sleeping patterns. How should you document your findings?
a. Pt. sleeps a lot.
b. Pt. appears to sleep a lot.
c. Pt. sleeps deeply.
d. Pt. appears to have slept from 2200 to 1200
19. A nursing assistant was assigned to give morning care to your patient. How should you document the care he received from the assistant?
a. Morning care given by Nancy Jones, NA.
b. Morning care given.
c. Morning care given by nurse's aide.
d. Morning care given by NJ.
20. A health care provider gives you a verbal order for digoxin 0.25 mg P.O. for your patient. How should you document it?
a. Record the order on the health care provider's order sheet and read it back.
b. Include the health care provider's prescriber number in the order.
c. Sign the health care provider's name.
d. Don't record anything. Wait for the health care provider to come by later and supply a written order.
21. Your patient told you that he isn't happy with the care he's been getting at your facility and that he's thinking of suing. How should you proceed?
a. Notify the patient's family and discuss the problem.
b. Fill out an event report.
c. Chart factually and defensively.
d. Document in the chart that you filed an event report.
22. An 83-year-old patient fell while getting out of bed. What information should you include in your documentation?
a. Mention that you completed an event report.
b. Describe what you saw and heard and the actions you took when you arrived at the patient's bedside.
c. Describe what you think occurred.
d. Describe another staff member's suggestions about how to prevent falls.
23. A 19-year-old patient who was recently diagnosed with diabetes asks to see his medical record. What should you do first?
a. Immediately let him view his chart.
b. Ask the patient if he has questions about his treatment.
c. Check with your nurse-manager.
d. Check with the health care provider.
24. An 81-year-old patient admitted with dehydration requires I.V. therapy. After establishing I.V. access, you must document
a. only the number of venipuncture attempts you made.
b. the date, time, and venipuncture site; type and gauge of the catheter; and number of venipuncture attempts you made.
c. only the name of the catheter you used.
d. only the date and time you established I.V. access.
25. A patient diagnosed with lower gastrointestinal bleeding is ordered a transfusion of 1 unit of packed red blood cells. What information should you document about this procedure?
a. confirmation that you alone verified the blood label information
b. only the patient's vital signs before the transfusion
c. patient's vital signs before, during, and after the transfusion as well as the total volume of blood transfused
d. only the patient's vital signs before and after the transfusion
26. Which abbreviations are on The Joint Commission'sDo not use list? Select all that apply.