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1. Which option is not a primary reason that documentation is important?
a. Documentation enables the team to provide care to meet a resident’s individual needs.
b. Documentation helps defend the nurse in the event of a possible lawsuit.
c. Documentation enables a patient to receive consistent care from one shift to the next.
d. Documentation is the basis for reimbursement to the facility. |
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2. What is a SOAP note?
a. Record of supplies used in patient hygiene
b. Record of an event during a patient’s stay, formatted according to the Simple Object Access Protocol (SOAP), enabling it to be easily transmitted between computers
c. Form of bar code
d. Record of patient data listing the patient’s subjective complaint, objective data recorded by the nurse, the nurse’s assessment of the situation, and the nurse’s plan of action |
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3. Which of the following is a true statement about documentation?
a. Nurses should keep records of patients’ wishes.
b. Patients do not have access to their own medical records.
c. The Outcomes and Assessment Information Set (OASIS) is a complete record of the health status of a patient.
d. The nurse is responsible for completing all of the Minimum Data Set (MDS). |
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4. Which one of the following is connected with the nursing home reform mandated by a 1987 law?
a. Resident Assessment Instrument (RAI)
b. HIPAA
c. OASIS
d. Fulmer SPICES |
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5. An older woman has diabetes mellitus and requires hemodialysis for renal failure. She is discharged to home to recover from a sternal wound infection and coronary artery bypass graft surgery (CABG). A home care nurse will provide wound care. Which of the following is the major justification for the complete and accurate documentation of this older adult’s care?
a. Requires complex health care
b. Has needs in multiple settings
c. Is at risk for iatrogenic problems
d. Has significant health care expenses |
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6. The nurse scans an older man’s identification band in preparation for medication administration. Which step should the nurse implement next?
a. Ask the patient to state his name.
b. Check for allergies to the medication.
c. Document the medication as given.
d. Administer the patient’s medication. |
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7. Which of the following does the nurse use to categorize the desired end result of nursing care delivered to a patient when using problem-oriented nurses’ notes?
a. North American Nursing Diagnosis Association (NANDA) nursing diagnosis
b. Nursing Goals Classification
c. Nursing Outcomes Classification (NOC)
d. Nursing Interventions Classification (NIC) |
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8. Which documentation tool does the nurse use to achieve optimal functional status for a nursing home resident?
a. Narrative patient progress notes
b. Problem-oriented documentation
c. Resource Utilization Group (RUG)
d. Resident Assessment Instrument (RAI) |
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9. Using the RAI, the nurse identifies a trigger for a male nursing home resident who requires an indwelling urinary catheter from the MDS. Which should the nurse do next?
a. Develop an individualized care plan.
b. Assign suitable nursing interventions.
c. Use the RAPs.
d. Institute agency-approved catheter care. |
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10. The federal government requires the use of a specific standardized documentation tool for home nursing care. Which information must a home nurse add to the approved documentation tool?
a. Activity
b. Vital signs
c. Functional
d. Demographic |
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11. The nurse must inform an older adult who does not speak English about patient rights. In addition, the nurse must have the adult sign the document about information access. Which intervention should the nurse use to maintain the confidentiality of this older adult?
a. Present the patient with a Spanish version of the information access document.
b. Have an English-speaking family member explain the document to the patient.
c. Explain the document to the patient using an interpreter to ensure understanding.
d. Instruct an interpreter to read the information access document to the resident privately. |
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1. The same nursing documentation record is used in every unit of a hospital. Why does a hospital use a standardized form for nursing documentation? (Select all that apply.)
a. Helps provide continuity of care
b. Standardizes patient care parameters
c. Assists in maintaining confidentiality
d. Reduces the number of medication errors
e. Provides the foundation for staffing levels
f. Allows for quality evaluations among units |
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2. The OASIS was implemented to provide the format for a comprehensive assessment in the home health care setting. How is this assessment tool used? (Select all that apply.)
a. To improve the quality of care
b. To improve the communication about the individual
c. To serve as a guide for reimbursement
d. To evaluate the level of patient disability |
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3. Which mental status assessment tool(s) would be appropriate for use in long-term care facilities? (Select all that apply.)
a. Fulmer SPICES
b. Clock Drawing Test
c. The Mini-Cog
d. Mini-Mental State Examination (MMSE) |
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