True or False
Include the date whenever a new entry is made.
In written notes, all writing must be legible and neat.
Use any abbreviations needed to shorten an entry.
Use correct spelling, grammar, and punctuation.
T
T
F
T
What basic observations can you make to determine a client’s ability to respond?
A. The client can state his or her name, the
time, and the location
B. The client can speak clearly
C. The client can follow directions
D. The family can answer questions
E. The client is easy to rouse
F. The client responds correctly to questions
A, B, C, E, F
When should the support worker contact the supervisor?
A. When the pharmacy delivers the client’s medications to the house.
B. When you believe the client’s safety is at risk. C. The support worker should provide the supervisor with hourly updates.
D. After completion of a procedure.
B
A. Client care plan B. Nursing diagnosis
C. Nursing intervention D. Care planning process
E. Medical diagnosis F. Evaluation
______ Identification of a disease or condition by a doctor
E
______ 8:45 a.m.
______ 4:00 p.m.
0845hr
1600 hr
Sign all entries with your name and title as required by your agency.
Skip lines between recorded entries.
Document what you or others did or observed.
Document all care and treatments early in the shift before beginning work.
T
F
F
F
1. What observations are important to determine how the bowels and bladder are functioning?
A. Amount, colour, and consistency of stool
B. Colour of the lips and nail beds
C. Frequency of bowel movements
D. Pain or difficulty urinating
E. Client’s control of the passage of urine
F. Frequency of urination
A, C, D, E, F
What information is charted on a graphic sheet.
A. Temperature, pulse, and respirations
B. Complaints of pain
C. Amount of food consumed
D. Bowel sounds
A
A. Client care plan B. Nursing diagnosis
C. Nursing intervention D. Care planning process
E. Medical diagnosis F. Evaluation
______ Determining whether the goals in the care plan have been met
F
______ 11:59 p.m.
______ 12:30 a.m.
2359 hr
1230 hr
Document in pencil.
Document your observations, interpretations, and judgements.
Document in a logical and sequential manner.
Avoid terms with more than one meaning.
F
F
T
T
What observations should be made about a client’s respirations?
A. Do both sides of the client’s chest rise and fall with respirations?
B. Is the client’s breathing noisy?
C. Does the client complain of difficulty breathing? D. Does the client complain of gas?
E. What is the amount and colour of sputum?
F. What is the frequency of the client’s cough? Is it dry or productive?
A, B, C, E, F
What statement about electronic documentation is correct?
A. You are able to use all types of abbreviations.
B. All spelling errors are automatically corrected. C. In general, staff can take tablets home to document on their own time.
D. It requires individual entries using a personal identification number (PIN) or code.
D
A. Client care plan B. Nursing diagnosis
C. Nursing intervention D. Care planning process
E. Medical diagnosis F. Evaluation
______ Description of a health problem that can be treated by nursing measures
B
______ 9:50 p.m.
______ midnight
2150 hr
0000 or 2400hr
Document any changes from normal or changes in the client’s condition.
Repeated complaints of pain can omitted when documenting
Paraphrase the client’s words to make the meaning more understandable.
For written documentation, use an eraser or correction fluid if you make an error.
T
F
F
F
What observations will help to determine whether a client is moving appropriately?
A. The client can squeeze your fingers with each hand
B. The client can move his or her arms and legs
C. The client’s movements are shaky or jerky
D. The client can ambulate without assistance
2. What are the four senses you use to obtain information about a client?
A. Smell
B. Hearing
C. Touch
D. Instinct
E. Sight
1. A, B, D
2. A, B, C, E
Which of these is a question about an activity of daily living?
A. Can the client perform personal care without help?
B. How much food on the tray did the client eat? C. What is the frequency of the client’s bowel movements?
D. Can the client move his or her arms and legs?
A
A. Client care plan B. Nursing diagnosis
C. Nursing intervention D. Care planning process
E. Medical diagnosis F. Evaluation
______ Written guide that gives direction about the care and services a client should receive
D
______ 6:30 a.m.
______ 10:00 p.m.
______ 1:30 p.m.
0630hr
2200hr
1330hr
Document safety measures used in caring for the client.
Objective data are things a client reports that you cannot observe by using your senses.
Subjective data are pieces of information you can obtain about a client using your senses.
When you document in the chart, you sign your name and write your title as per agency policy after each entry.
T
F
F
T
When reporting to the nurse, you should do which of the following?
A. Report what you observed and did yourself
B. Report what other support workers did
C. Report any changes in the client’s condition.
D. Report promptly, thoroughly, and accurately
E. Report only at the end of your shift
2. What basic observations can you make to determine a client’s ability to respond?
A. The client can state his or her name, the time, and the location
B. The client can speak clearly
C. The client can follow directions
D. The family can answer questions
E. The client is easy to rouse
F. The client responds correctly to questions
A, C, D
A, B, C, E, F
1. If you make an error when recording, you should:
A. Put an X through the error, and write “error” over it
B. Erase the error
C. Draw a single line through the error, and write “error” over it
D. Use correction fluid
2. A data form:
A. Is used in long-term care settings to detail a person's physical, emotional, social, and intellectual health
B. Is used in home care settings to assess changes that may be needed to the home
C. Includes boxes that are checked for the day on which care or service was provided
D. Is another name for Kardex
C
A
A. Client care plan B. Nursing diagnosis
C. Nursing intervention D. Care planning process
E. Medical diagnosis F. Evaluation
______ Method used by nurses to plan and deliver nursing care
______ Action taken by a nursing team member to help the client reach a goal
D
C
______ 7:30 p.m.
______ 3:30 p.m.
______ 2:45 p.m.
1730hr
1530hr
1445hr