Patient Observation & Documentation Flashcards
7 cards from real PCA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Observation & Documentation flashcards as text
What is the purpose of an intake and output (I&O) record for a patient?
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.
A patient who was alert yesterday is now confused and difficult to rouse. This change should be:
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.
Which abbreviation correctly refers to 'three times a day' in documentation?
Answer: TID
TID stands for 'ter in die,' the Latin term meaning three times a day, commonly used in medical documentation.
A PCA finishes documenting and realizes they made an error. What is the correct way to fix a handwritten chart entry?
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.
A patient reports feeling 'light-headed' when standing up. What is the PCA most likely observing signs of?
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.
When measuring a patient's temperature orally, the reading is 101.5°F. What should the PCA do?
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.
What does 'NPO' mean in patient documentation?
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.