RPN Documentation and Reporting 5

Question 1

A nurse is documenting informed consent. Which element is NOT required as part of informed consent documentation?

Accepted Answer

The nurse's personal opinion on whether the patient should proceed

Answer

Informed consent documentation captures the patient's decision after receiving objective information; the nurse's personal opinion is not a required element.

Question 2

Which of the following best describes 'charting by exception' (CBE)?

Accepted Answer

Only documenting findings that deviate from established norms or the care plan

Answer

Charting by exception documents only abnormal findings or deviations from the plan, assuming normal findings unless noted otherwise.

Question 3

A nurse suspects a patient is experiencing elder abuse. Mandatory reporting laws require the nurse to report this to:

Accepted Answer

The appropriate adult protective services or designated agency as required by state law

Answer

Nurses are mandated reporters in all U.S. states and must report suspected elder abuse to adult protective services or the legally designated agency.

Question 4

How long must most hospitals in the U.S. retain adult patient medical records according to federal regulations and accreditation standards?

Accepted Answer

At least 5 to 10 years (varies by state), or until the patient's 21st birthday if a minor

Answer

Medical record retention requirements vary by state but generally require retention for a minimum of 5–10 years for adults, with extended requirements for minors.

Question 5

When a nurse documents 'patient tolerated procedure well' without supporting observations, this is an example of:

Accepted Answer

A vague, conclusory statement that lacks objective detail

Answer

Phrases like 'tolerated well' are conclusory and do not provide the objective data needed to support the statement or defend care if questioned.

RPN - Registered Practical Nurse Practice Test

RPN - Registered Practical Nurse Practice Test

RPN Documentation and Reporting 5