Chapter 3 NCLEX Review Questions Lizs0823Top creator on Quizlet Save Learn1 / 7Study using Learn PIE Choose an answer When charting by exception, which acronym is generally used?As a newly hired nurse, what is the best way to chart using correct abbreviations?A patient has been admitted to the medical floor. Whose responsibility is it to complete the patient's initial admission nursing history, physical assessment, and development of the care plan?What form on the patient's chart do nurses record their observations, care given, and the patient's responses?Don't know?
When charting by exception, which acronym is generally used?
PIE As a newly hired nurse, what is the best way to chart using correct abbreviations?Check to see if the facility has a published list of abbreviations.Considering the patient's medical record is a legal document, what is the most important consideration the nurse should make?Clearly indicate goal-directed nursing care During which phase of the nursing process does documentation take place?Implementation The nurse is organizing the tasks and care that are required throughout the work shift. What is the best time to plan on documenting patient care?As soon as possible after completion of care What form on the patient's chart do nurses record their observations, care given, and the patient's responses?Nurses' notes
What is considered an appraisal by a professional co-worker of the manner in which an individual nurse conducts practice, education, or research?Peer review A patient has been admitted to the medical floor. Whose responsibility is it to complete the patient's initial admission nursing history, physical assessment, and development of the care plan?
RN Computer charting is becoming an increasingly common way to document your patients.How often should the password be changed?At the discretion of the institution The nurse is preparing to document patient care. What data is most important for the nurse to include? (Select all that apply.) -Time of care -Type of procedure performed -Patient's pain level Terms (10) Hide definitions