PCA Patient Observation & Documentation 3 — Questions and Answers
Question 1: What is the purpose of an intake and output (I&O) record for a patient?
- To track how often the patient exercises
- To monitor the balance of fluids consumed and excreted (Correct answer)
- To document the patient's food preferences
- To record medication administration times
Correct answer: To monitor the balance of fluids consumed and excreted
I&O records help the care team monitor fluid balance, which is essential for detecting dehydration, edema, and kidney issues.
Question 2: A patient who was alert yesterday is now confused and difficult to rouse. This change should be:
- Noted in the chart at the end of the shift
- Reported to the nurse immediately as a possible medical emergency (Correct answer)
- Attributed to normal aging and not reported
- Monitored for another 24 hours before reporting
Correct answer: Reported to the nurse immediately as a possible medical emergency
A sudden change in mental status is a serious sign that may indicate stroke, medication reaction, or infection and requires immediate reporting.
Question 3: Which abbreviation correctly refers to 'three times a day' in documentation?
- BID
- TID (Correct answer)
- QID
- PRN
Correct answer: TID
TID stands for 'ter in die,' the Latin term meaning three times a day, commonly used in medical documentation.
Question 4: A PCA finishes documenting and realizes they made an error. What is the correct way to fix a handwritten chart entry?
- Use white-out to cover the mistake
- Scribble over the error until it is unreadable
- Draw a single line through the error, write 'error,' and initial it (Correct answer)
- Tear out the page and rewrite the entry
Correct answer: Draw a single line through the error, write 'error,' and initial it
The correct method is a single line through the error with the word 'error' and the caregiver's initials to preserve the original entry's readability.
Question 5: A patient reports feeling 'light-headed' when standing up. What is the PCA most likely observing signs of?
- Hypertension
- Orthostatic hypotension (Correct answer)
- Bradycardia
- Hyperglycemia
Correct answer: Orthostatic hypotension
Orthostatic hypotension is a drop in blood pressure upon standing that causes dizziness or light-headedness and is a common fall risk.
Question 6: When measuring a patient's temperature orally, the reading is 101.5°F. What should the PCA do?
- Give the patient a glass of water and recheck in 30 minutes
- Apply a cool cloth and document the fever without reporting
- Report the elevated temperature to the supervising nurse promptly (Correct answer)
- Assume the thermometer is inaccurate and use a different one
Correct answer: Report the elevated temperature to the supervising nurse promptly
A temperature of 101.5°F is a fever and must be reported to the nurse so the cause can be investigated and treatment initiated.
Question 7: What does 'NPO' mean in patient documentation?
- No physical obstacles in the room
- Nothing by mouth — patient must not eat or drink (Correct answer)
- Normal patient output recorded
- New patient orientation required
Correct answer: Nothing by mouth — patient must not eat or drink
NPO stands for 'nil per os,' meaning nothing by mouth, and is ordered before surgeries or certain medical tests.
PCA Patient Observation & Documentation 3
What is the purpose of an intake and output (I&O) record for a patient?