Chapter 20: Documenting and Reporting - Nurselytic

Questions 21

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ATI LPN TextBook-Based Test Bank

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 physicians order reads up ad lib. What does this mean in terms of patient activity?

Correct Answer: B

Rationale: Up ad lib' means the patient may be up and active as desired, without restrictions.

Question 2 of 5

Which of the following abbreviations are on the Joint Commission do not use abbreviations? Select all that apply.

Correct Answer: A,B,E

Rationale: The Joint Commission prohibits abbreviations like U, QD, and > due to their potential for misinterpretation, which can lead to medication errors.

Question 3 of 5

What is the primary purpose of focus charting?

Correct Answer: C

Rationale: Focus charting centers on patient concerns, allowing nurses to document issues and responses systematically.

Question 4 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 5 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.

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