3/23/2017 MedicalChartingQuiz

MedicalChartingQuiz

Your Name: Rebecca Bossack

Date/Time Student Score Passing score Result

March 23, 2017 5:45

80% (200 points) 80% (200 points) Passed
PM

# Question Result Awarded Points

1. Which category of nursing diagnosis consists of potential 0 10

problems that the patient is at risk for developing?

At the beginning of the shift, balance the Opioid Inventory

2. 10 10
Control Form with a nurse from the outgoing shift.

A common error in recording a patients intake and output is not

3. 0 10
including:

You are caring for a postoperative patient with an abdominal

incision. At 6 p.m. he was given morphine sulfate (MS) 3 mg IVP
4. for pain described as 9/10 per pain scale and at 6:30 you 10 10
returned to re-evaluate the pain level. You evaluation is best
stated as:

5. What is the goal of a care plan? 10 10

6. Which of the following is the preferred entry into a chart? 10 10

Always circle any medication that was NOT administered and

7. 10 10
write the reason why it was omitted in the MAR.

You are assessing the patients left lower ankle and note edema.
8. You press on the patients ankle and it leaves a deep indentation. 10 10
You should chart this as:

What is the best form to record the amount of IV uid that was
9. 10 10
given to a patient?

In a malpractice case, if a chart shows that an important

treatment was ordered, but nothing in the chart shows that is
10. 10 10
was performed by the nurse, what is the judge likely to
conclude?

If you make an error while charting, you should cover up the

11. error with white-out or heavily cross out the text making it 10 10
unreadable.

A nurse enters a room and sees that the patients intravenous

line is disconnected from the patients arm. The patient says to
12. 10 10
her, I dont want this thing hooked up to me anymore. What
should the nurse chart?

Medications that are given regularly to the patient to maintain a

13. therapeutic level such as once a day for 7 days are documented 0 10
as:

14. Which category of nursing diagnosis is a problem that consists of 10 10

a cluster of other diagnoses such as chronic pain?

15. The nurse is caring for a patient with a nursing diagnosis of 10 10

impaired skin integrity related to a stage 1 pressure ulcer. The
most appropriate goal for this patient is:
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3/23/2017 MedicalChartingQuiz

# Question Result Awarded Points

A nurse should think of charting as writing a news report about

16. 10 10
the patient rather than the patients life history.

The medical laboratory never has to be informed of medication

17. 10 10
given to the patient immediately prior to taking a blood sample.

Your patient is a 68-year-old male who is 14 hours post open

cholecystectomy. The report from the previous nurse indicated
the following: alert and oriented times 3, pleasant, cooperative,
and appropriate, surgical dressing dry and intact, vital signs
18. within normal limits, pain level 2/10 as per pain scale. When you 0 10
evaluate the patient for your a.m. assessment, he calls you by his
daughters name, shows facial grimacing with incisional
palpation, unable to describe pain level, and tells you that hes
late for work. What should you write in his chart?

. Which charting format contains subjective data, objective data,

19. 10 10
assessment data, a care plan, intervention and evaluation data?

Which of the following are common mistakes when measuring a

20. 0 10
patients output?

21. When is the most appropriate time to create a care plan? 10 10

The nursing process, referred to as ADPIE, is a good approach to

22. 10 10
follow when documenting patient care.

Which charting format contains subjective data, objective data,

23. 10 10
assessment data and a care plan?

24. When is the most appropriate time to modify a care plan? 10 10

25. If a nurse is having diculty in reading a medical order in the 10 10

patients chart, what should she do?

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