C HAPTER 07: D OCUMENTATION OF N URSING
C ARE
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. A nurse begins the shift caring for a patient who has just returned from
the recovery room after surgery. It is mo st important to document:
a. at the end of the shift so that the nurse can give his full attention
and time to the patient’s needs during the shift.
b. a nursing care plan in the medical record before assessing the
patient so that the nurse can identify prioriti es.
c. at least three times during the shift: at the beginning, in the middle,
at the end, and as needed.
d. an initial assessment of the patient and a plan based on the needs of
the patient as assessed at the beginning of the shift.
ANS: D
An initial assessment should be performed at the beginning of the shift
and promptl y documented. It will determine the plan and priorities.
Documentation should be done as close to the time of occurrence as
possible.
DIF: Cognitive Level: Application REF: p. 94|Box 7-4
OBJ: Theory #1 TOP: The Charting Process KEY:
, Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
2. The nurse uses the flow sheet in patient care documentation primaril y:
a. to track routine assessments, treatments, and frequentl y given care.
b. to eliminate written narratives and to save time.
c. in computer-assisted charting to create visual graphs showing
change.
d. to improve continuity of care and exchange of information among
disciplines.
ANS: A
Flow sheets are a time saver but do not eliminate narrative charting.
They are used to document information that is routine and that would
be “lost” in a narrative note.
DIF: Cognitive Level: Comprehension REF: p. 86
OBJ: Theory #4 TOP: Flow Sheets KEY: Nursin g
Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
3. When the nurse documents in narrative or source -oriented format about
the patient’s condition and the nursing care provided, it is appropriate for
him to record:
a. “Patient will go to physical therapy after lunch.”
b. “Diabetes in excellent control. Continue with current insulin
schedule.”
c. “I gave the patient a thorough bath and cut her fingernails.”
d. “To x-ray by wheelchair at 10:30 AM IV infusing in left arm.”
, ANS: D
Documentation that includes specific information regarding time,
method of travel, destination, and current status (that an IV medication
is infusing) is a clear example of source -oriented charting.
DIF: Cognitive Level: Application REF: p. 86 OBJ:
Theory #4 TOP: Source-Oriented Charting KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment: Coordinated Care
4. The nurse understands that a face sheet contains information pertaining to:
a. serial measurements and ob servations, such as temperature, pulse,
respiration, blood pressure, and weight.
b. plan of care for the patient, including nursing diagnoses,
goals/expected outcomes, and nursing interventions.
c. written report of the nursing process, record of interventions
implemented, and the patient’s response to them.
d. patient data, including patient’s name, address, phone number,
insurance company, and admitting diagnosis.
ANS: D
The t ype of information contained on a face sheet includes patient data,
including the patient’s name, address, phone number, next of kin,
hospital identification number, religious preference, place of
employment, insurance company, occupation, name of admitting
physician, and admitting diagnosis.
C ARE
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. A nurse begins the shift caring for a patient who has just returned from
the recovery room after surgery. It is mo st important to document:
a. at the end of the shift so that the nurse can give his full attention
and time to the patient’s needs during the shift.
b. a nursing care plan in the medical record before assessing the
patient so that the nurse can identify prioriti es.
c. at least three times during the shift: at the beginning, in the middle,
at the end, and as needed.
d. an initial assessment of the patient and a plan based on the needs of
the patient as assessed at the beginning of the shift.
ANS: D
An initial assessment should be performed at the beginning of the shift
and promptl y documented. It will determine the plan and priorities.
Documentation should be done as close to the time of occurrence as
possible.
DIF: Cognitive Level: Application REF: p. 94|Box 7-4
OBJ: Theory #1 TOP: The Charting Process KEY:
, Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
2. The nurse uses the flow sheet in patient care documentation primaril y:
a. to track routine assessments, treatments, and frequentl y given care.
b. to eliminate written narratives and to save time.
c. in computer-assisted charting to create visual graphs showing
change.
d. to improve continuity of care and exchange of information among
disciplines.
ANS: A
Flow sheets are a time saver but do not eliminate narrative charting.
They are used to document information that is routine and that would
be “lost” in a narrative note.
DIF: Cognitive Level: Comprehension REF: p. 86
OBJ: Theory #4 TOP: Flow Sheets KEY: Nursin g
Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
3. When the nurse documents in narrative or source -oriented format about
the patient’s condition and the nursing care provided, it is appropriate for
him to record:
a. “Patient will go to physical therapy after lunch.”
b. “Diabetes in excellent control. Continue with current insulin
schedule.”
c. “I gave the patient a thorough bath and cut her fingernails.”
d. “To x-ray by wheelchair at 10:30 AM IV infusing in left arm.”
, ANS: D
Documentation that includes specific information regarding time,
method of travel, destination, and current status (that an IV medication
is infusing) is a clear example of source -oriented charting.
DIF: Cognitive Level: Application REF: p. 86 OBJ:
Theory #4 TOP: Source-Oriented Charting KEY: Nursing
Process Step: Implementation MSC: NCLEX: Safe,
Effective Care Environment: Coordinated Care
4. The nurse understands that a face sheet contains information pertaining to:
a. serial measurements and ob servations, such as temperature, pulse,
respiration, blood pressure, and weight.
b. plan of care for the patient, including nursing diagnoses,
goals/expected outcomes, and nursing interventions.
c. written report of the nursing process, record of interventions
implemented, and the patient’s response to them.
d. patient data, including patient’s name, address, phone number,
insurance company, and admitting diagnosis.
ANS: D
The t ype of information contained on a face sheet includes patient data,
including the patient’s name, address, phone number, next of kin,
hospital identification number, religious preference, place of
employment, insurance company, occupation, name of admitting
physician, and admitting diagnosis.
