RPN - Registered Practical Nurse Documentation and Reporting Questions and Answers

Question 1

An RPN makes an error while documenting a client's vital signs on a paper chart. Which action is the correct procedure for correcting this mistake?

Accepted Answer

Draw a single line through the incorrect entry, write 'error' or 'mistaken entry' above it with the nurse's initials, and then record the correct information.

Answer

Use correction fluid to cover the error and write the correct information.

Answer

Completely black out the error with a marker and chart the correct data in the next available space.

Answer

Leave the error as is and add a new note at the end of the shift explaining the correction.

Question 2

An RPN is calling a physician to report a client's sudden onset of shortness of breath. Using the SBAR communication tool, which of the following statements represents the 'Assessment' component?

Accepted Answer

"I believe the client may be experiencing a pulmonary embolism as his oxygen saturation is 88% on room air and he is tachycardic."

Answer

"The client was admitted yesterday with a fractured hip and has no history of respiratory issues."

Answer

"I request an order for a portable chest x-ray and for you to come assess the client immediately."

Answer

"This is Nurse Lee calling from Unit 4 about Mr. Chen in room 402B, who is experiencing new-onset dyspnea."

Question 3

Which of the following documentation entries is the best example of objective data?

Accepted Answer

"Abdominal dressing is dry and intact with no erythema or swelling noted at the incision site."

Answer

"Client seems depressed and is refusing to eat lunch."

Answer

"Client had a good day and was pleasant to staff."

Answer

"Client is complaining of severe pain and appears uncomfortable."

Question 4

An RPN realizes they forgot to document a medication that was administered two hours prior. What is the proper procedure for adding this information to the client's electronic health record?

Accepted Answer

Create a new entry, clearly labeled as a 'late entry,' and record the actual time the medication was administered.

Answer

Ask a colleague to enter the medication documentation for them.

Answer

Document the medication as if it were just given at the current time.

Answer

Wait until the next shift to see if the oncoming nurse can add the entry.

Question 5

An RPN is caring for a client who had a fall. The RPN completes an incident report according to facility policy. How should this event be documented in the client's official health record?

Accepted Answer

Document a factual account of the fall, the client's response, and the interventions performed, without mentioning the incident report.

Answer

Write "Incident report completed and filed with risk management" in the progress notes.

Answer

Place a copy of the incident report in the client's chart for the physician to review.

Answer

Only document the fall in the incident report to prevent legal discovery of the event.

Question 6

According to Ontario's Personal Health Information Protection Act (PHIPA), an RPN understands that they can access a client's personal health information under which of the following circumstances?

Accepted Answer

Only when it is necessary for the direct provision of care to that specific client.

Answer

When a colleague from another unit asks about the client's diagnosis out of curiosity.

Answer

If the client is a family member and the RPN wants to check on their progress.

Answer

To review the chart of an interesting case on the unit for educational purposes.