Nursing Documentation Questions and Answers Already Graded A
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Module
Nursing
Institution
Nursing
Nursing Documentation Questions and
Answers Already Graded A
What is a key component of effective nursing documentation?
A) Providing detailed descriptions of personal impressions
B) Using standardized abbreviations and terminology
C) Including subjective opinions about patient care
D) Fo...
Nursing Documentation Questions and
Answers Already Graded A
What is a key component of effective nursing documentation?
A) Providing detailed descriptions of personal impressions
B) Using standardized abbreviations and terminology
C) Including subjective opinions about patient care
D) Focusing only on the patient's medical history
✔✔ B) Using standardized abbreviations and terminology
When documenting a patient’s response to a new medication, what should be included?
A) Only the dosage and administration time
B) The patient’s subjective feelings and objective observations
C) The names of other medications the patient is taking
D) The nurse’s thoughts about the effectiveness of the medication
✔✔ B) The patient’s subjective feelings and objective observations
What is the correct procedure if a nurse realizes a documentation entry was made in error?
A) Completely delete the incorrect entry from the record
1
, B) Cross out the error and write a new entry in a different color
C) Correct the error by striking through it, writing "error," and adding the correct information
D) Leave the incorrect entry and add a new entry with the correct information
✔✔ C) Correct the error by striking through it, writing "error," and adding the correct
information
Why is it important to document the time of a patient's vital signs?
A) To create a record of the nurse’s work schedule
B) To ensure accurate tracking and correlation with the patient’s condition and interventions
C) To comply with hospital administrative policies
D) To provide evidence for billing purposes
✔✔ B) To ensure accurate tracking and correlation with the patient’s condition and interventions
How should a nurse document a conversation with a patient about a change in treatment plan?
A) Briefly note that a discussion took place without details
B) Document the details of the conversation, including the patient’s understanding and
agreement
C) Only document the change in treatment plan
D) Record the conversation in a separate log book
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