Comprehensive Study Guide with Verified
Questions & Answers
SOAP modified format - {answer}-Subjective
Objective
Assessment
Plan
What color ink should be used when documenting on paper -
{answer}-Permanent black ink
,What is the correct order for vital signs - {answer}-T, P, RR,
BP, extremity, pt position, SPO2
What should be at the top of every page of documentation -
{answer}-Patient initials and date and time of entry
What should be at the end of every documentation entry -
{answer}-Interviewers signature
How do you correct a mistake in documentation - {answer}-1)
Draw a single line through the incorrect documentation
2) Write error above the entry
3) Initial and date the crossed out entry
Documentation tips - {answer}-1) Avoid complete sentences
2) Do not use A, an, the
3) Do not put opinion in notes
4) Avoid use of normal or within normal limits
Normal oral temp range - {answer}-96.4 - 99.1 F
Febrile - {answer}-With fever
,Afebrile - {answer}-Without fever
Hyperthermia symptoms - {answer}-1) Cessation of shivering
2) Bradycardia
3) Decrease in respiratory minute volume
Most common and easy method of assessing temperature -
{answer}-Oral
What methods of assessing temperature reflects core
temperature - {answer}-1) Oral
2) Rectal
3) Tympanic
4) Temporal Artery
What is the least accurate method of assessing temperature -
{answer}-axillary
Which patients are contraindicated for rectal temperature
readings - {answer}-Patients with increased HR
, Preferred method of taking infants and small children's
temperatures - {answer}-Rectal
Pulse deficit - {answer}-- Difference between apical
peripheral pulse
Pulse amplitude scale - {answer}-0 = no pulse
1 = diminished, weak
2 = normal and expected
3 = full or strong
4 = bounding
Which pulses are assessed during a routine physical
assessment? - {answer}-1) Apical
2) Radial
3) Dorsalis pedis
4) Posterior tibialis
Normal heart rate in resting adult - {answer}-60 to 100 bpm
Well trained athletes heart rate - {answer}-Heart rate less
than 60 bpm