Documentation
A nurse witnesses a patient fall at 1400 but doesn't chart it until 1800. What must be included in the chart?
The actual time the event occurred and that it is a late entry.
(what is late entry?)
A nurse uses hand sanitizer after touching a bedrail. Which link in the chain of infection is she trying to interrupt?
Mode of transmission.
Which vital sign would you assess most carefully after administering a beta blocker?
Pulse.
A patient's BP is 168/96 on three separate visits.
What chronic condition should be suspected?
Hypertension
What body system is most at risk for atelectasis during prolonged bed rest?
Respiratory.
Which type of charting is better:
"Patient was rude"
OR
"Patient crossed arms, raised voice, and stated 'leave me alone'"
What is Objective Documentation?
A patient develops pneumonia 5 days after admission. What type of infection is this?
Healthcare-associated infection.
A patient's pulse is regular but very slow at 48 bpm.
What term describes this?
Bradycardia.
A patient reports:
"The pain feels sharp and stabbing."
Which OPQRST category is being assessed
Quality.
Why are pillows often placed between a patient's knees when side-lying?
Alignment and pressure reduction.
A patient's daughter tells the nurse that her father has been confused all morning. How should this information be documented?
Document the information and identify the daughter as the source.
A nurse removes contaminated gloves and immediately touches her face.
What infection control principle was broken?
Self-contamination.
A nurse counts respirations immediately after the patient runs to the washroom.
Why might this be inaccurate?
Exercise temporarily increases respiratory rate
A patient says:
"It hurts in my shoulder but travels down my arm."
Which OPQRST category?
Region/Radiation.
A patient has been immobile for two weeks and now cannot fully straighten their elbow.
What complication has developed?
Contracture.
Why should documentation never be completed before a skill is performed?
It may not accurately reflect what actually occurred.
A patient has MRSA in a wound.
What type of isolation would you expect?
Contact precautions.
A patient has cold fingers and dark nail polish.
Which vital sign might be difficult to obtain accurately?
Oxygen saturation
Why is the two-step BP method more accurate than the one-step method?
Helps identify the pulse obliteration point and avoids missing an auscultatory gap.
Why should nurses encourage postoperative patients to ambulate as soon as safely possible?
Prevent complications of immobility.
Give two situations where written consent may be required.
Name 6 of the 6 links in the chain of infection.
Agent → Reservoir → Exit → Transmission → Entry → Host
What is the difference between a pulse rate and a pulse rhythm?
What is pulse pressure?
Difference between systolic and diastolic pressure.
Name 5 complications of immobility.
✅ Pressure injuries (pressure ulcers)
✅ Deep vein thrombosis (DVT)
✅ Pneumonia
✅ Atelectasis
✅ Contractures
✅ Muscle atrophy
✅ Deconditioning
✅ Constipation
✅ Urinary tract infections (UTIs)
✅ Orthostatic hypotension
✅ Falls
✅ Pulmonary embolism (PE)