89

Documenting,

Reporting, Conferring,

and Using Informatics

CHAPTER^17

PRACTICING FOR NCLEX

MULTIPLE CHOICE QUESTIONS

Circle the letter that corresponds to the best

answer for each question.

1.Which of the following is a nurse’s best

defense against allegations of negligence by a

patient or patient’s surrogate?

a.Nursing team

b.Flow sheet

c.Medication record

d.Patient record

2.Which of the following statements regarding

the patient record is accurate?

a.A patient’s chart may be shared only with

close family members.

b.Student nurses are not granted access to

patient records.

c.The patient record is generally the responsi-

bility of one caregiver.

d.Most patient records are microfilmed and

stored in computers.

3.In which of the following systems would a

nurse organize data according to the SOAP

format?

a.Source-oriented method

b.PIE charting method

c.Problem-oriented method

d.Focus charting method

4.Abnormal status can be seen immediately with

narrative easily retrieved in which of the

following documentation formats?

a.Charting by exception

b.PIE

c.Narrative notes

d.SOAP notes

5.Which of the following is a key component to

facilitate data and outcome comparisons by

using uniform definitions to create a common

language among multiple healthcare data

users?

a.Kardex care plan

b.Minimum data sets

c.Computer-based records

d.Critical/collaborative pathways

LWBK696-C17_p89-95.qxd 9/2/10 9:28 AM Page 89 Aptara Inc