Nursing Fundamentals-Unit 2.02

An example of patient observation by using sight is:

• wheezing

• jaundice

• tachycardia

• foul odor urine

An example of pt. observation by using touch is:

• wheezing

• bruising

• slurred speech

• breast lump

Which is objective data?

• red face

• states has a headache

• complains of chest pain

• states coughing one week

Which is subjective data?

• red face

• Temp 101.6

• complains of chest pain

• pulse irregular

What should you do with a medical record after the resident dies?

• Give to the family right away

• Shred it immediately

• Keep it in locked files for 7 years

• Throw it in the trash can immediately

The nurse may give a report about the patient to:

• the next shift coming in to work

• the resident’s neighbor

• the spouse

• the nurses on the next unit

When charting, you would make sure you always:

• use long sentences

• catch up at the end of the shift

• use pencil to erase

• use short, concise phrases

Which of the following is true of oral reports?

• NA’s should use facts when making oral reports

• NA’s should use opinions when making oral reports

• NA’s should make oral reports directly to the resident’s families

• NA’s should NOT make oral reports; they only need to complete written reports

Which of the following is true of a resident’s medical chart?

• A medical chart is the legal record of a resident’s care

• Not all care needs to be documented

• Documentation can be put off until the next day

• Medical charts are not considered legal documents

When should care be documented?

• Before care is given

• Immediately after care is given

• At the end of the day

• Whenever there is time