INACE Documentation and Record Keeping 2

Question 1

When a nurse aide makes an error in a written medical record, what is the correct procedure?

Accepted Answer

Draw a single line through the error, write 'error,' initial it, and enter the correct information

Answer

A single line through the error preserves the original entry and maintains the integrity of the legal record.

Question 2

Which of the following is an example of objective documentation?

Accepted Answer

'The resident's blood pressure is 140/90 mmHg.'

Answer

Objective documentation records measurable, observable facts rather than assumptions or interpretations.

Question 3

A nurse aide notices a resident refused breakfast. How should this be documented?

Accepted Answer

'Resident refused breakfast tray at 0800.'

Answer

Documentation should record exactly what happened using factual, non-judgmental language.

Question 4

What does the abbreviation 'NPO' mean in medical documentation?

Accepted Answer

Nothing by mouth

Answer

NPO stands for 'nil per os,' a Latin phrase meaning nothing by mouth, indicating the patient should not eat or drink.

Question 5

How soon after care is provided should a nurse aide document the care?

Accepted Answer

As soon as possible after providing the care

Answer

Timely documentation ensures accuracy and prevents errors that can occur when relying on memory over time.

(INACE) Illinois Nurse Assistant Competency Exam Practice Test