Documentation of Nursing Care Study Guide Questions and Answers Rated A+
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Course
Nursing Care Study
Institution
Nursing Care Study
Documentation of Nursing Care Study
Guide Questions and Answers Rated A+
What is the primary purpose of documenting nursing care?
A) To provide a personal journal of the nurse's experiences
B) To ensure continuity of care and communication among healthcare providers
C) To comply with hospi...
Documentation of Nursing Care Study
Guide Questions and Answers Rated A+
What is the primary purpose of documenting nursing care?
A) To provide a personal journal of the nurse's experiences
B) To ensure continuity of care and communication among healthcare providers
C) To comply with hospital policy alone
D) To create a record for research purposes
✔✔ B) To ensure continuity of care and communication among healthcare providers
What is a key characteristic of effective nursing documentation?
A) It includes as much personal opinion as possible
B) It uses complex medical jargon
C) It is clear, concise, and objective
D) It omits any negative patient information
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,✔✔ C) It is clear, concise, and objective
Which of the following should be included in a nursing note after administering medication?
A) The name of the medication, dose, and time of administration
B) The nurse’s personal opinion about the patient’s condition
C) The name of the manufacturer of the medication
D) A detailed history of the patient’s previous medication use
✔✔ A) The name of the medication, dose, and time of administration
How should a nurse document a patient’s refusal of a recommended treatment?
A) Write a brief note stating the patient’s refusal
B) Record the refusal, including the reason given and any education provided
C) Document only that the patient did not follow the treatment plan
D) Omit the refusal if the patient did not provide a reason
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, ✔✔ B) Record the refusal, including the reason given and any education provided
What is an important aspect of documenting a patient’s vital signs?
A) Only documenting when vital signs are abnormal
B) Using subjective language to describe the vital signs
C) Recording the date, time, and exact readings of the vital signs
D) Excluding the vital signs if they are within normal range
✔✔ C) Recording the date, time, and exact readings of the vital signs
How should a nurse correct a documentation error?
A) Erase the incorrect information and rewrite the correct data
B) Cross out the error with a single line, write “error,” and correct the entry
C) Ignore the mistake and move on to the next entry
D) Ask another nurse to correct it for you
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