PCA Patient Observation & Documentation 3

Question 1

What is the purpose of an intake and output (I&O) record for a patient?

Accepted Answer

To monitor the balance of fluids consumed and excreted

Answer

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:

Accepted Answer

Reported to the nurse immediately as a possible medical emergency

Answer

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?

Accepted Answer

TID

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

Orthostatic hypotension

Answer

Orthostatic hypotension is a drop in blood pressure upon standing that causes dizziness or light-headedness and is a common fall risk.

(PCA) Personal Care Assistant Practice Test

(PCA) Personal Care Assistant Practice Test

PCA Patient Observation & Documentation 3