ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 20 : Documenting and Reporting Questions
Question 1 of 5
A nurse organizes patient data using the SOAP format. Which of the following would be recorded under S of this acronym?
Correct Answer: A
Rationale: The 'S' in SOAP stands for subjective data, which includes the patient's complaints, such as pain.
Question 2 of 5
Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse?
Correct Answer: B
Rationale: Charting by exception only documents deviations from the norm, which may omit critical details, making it less defensible in court.
Question 3 of 5
Which of the following information would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply.
Correct Answer: A,B,D,F
Rationale: The minimum data set includes demographic and administrative data like sex, admission date, insurance, and ethnicity to ensure standardized reporting.
Question 4 of 5
A nurse has access to computerized standardized plans of care. After printing one for a patient, what must be done next?
Correct Answer: C
Rationale: Standardized care plans must be tailored to the patient's unique needs to ensure appropriate and effective care.
Question 5 of 5
What part of the patients record is commonly used to document specific patient variables, such as vital signs?
Correct Answer: D
Rationale: The graphic record is designed to track measurable variables like vital signs in a clear, visual format.