UNAR Understanding Medical Documentation 3

Question 1

In medical documentation, the abbreviation 'PRN' means:

Accepted Answer

As needed

Answer

PRN is a Latin abbreviation for 'pro re nata,' meaning 'as needed,' commonly used for medications or treatments given only when required.

Question 2

What does the abbreviation 'NPO' mean in a resident's care plan?

Accepted Answer

Nothing by mouth

Answer

NPO means 'nihil per os' (nothing by mouth) and restricts the resident from eating or drinking, often before a procedure.

Question 3

The abbreviation 'SOB' in medical charting refers to:

Accepted Answer

Shortness of breath

Answer

SOB stands for shortness of breath and is an important clinical finding that must be documented and reported promptly.

Question 4

When a nursing assistant charts 'resident ambulated 20 feet with walker, tolerated well,' this is an example of:

Accepted Answer

Objective, factual documentation

Answer

Objective documentation records specific, measurable facts observed by the caregiver without interpretation or opinion.

Question 5

Which of the following is an example of SUBJECTIVE documentation?

Accepted Answer

Resident seems unhappy today

Answer

Subjective documentation reflects the caregiver's opinion or interpretation rather than observable, measurable facts.

(UNAR) Utah Nursing Assistant Registry Practice Test