Question 1

Under which category of SOAP charting would the nurse look to determine whether or not a client had reported having nausea?

Accepted Answer

A) Subjective data 
B) Objective data 
C) Assessment 
D) Plan 
A) Subjective data 
B) Objective data 
C) Assessment 
D) Plan

Question 2

A nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording.When searching for the most recent physician's orders,the nurse should look in which section?

Accepted Answer

A) Database 
B) Problem list 
C) Plan of care 
D) Progress notes 
A) Database 
B) Problem list 
C) Plan of care 
D) Progress notes

Question 3

Which of the following is a charting ERROR?

Accepted Answer

A) Using a black ballpoint pen to document 
B) Hand printing nurses' notes because one's cursive writing is hard to read 
C) Signing nurses' note that the relief nurse wrote earlier in the shift 
D) Including the date and time in each chart entry 
A) Using a black ballpoint pen to document 
B) Hand printing nurses' notes because one's cursive writing is hard to read 
C) Signing nurses' note that the relief nurse wrote earlier in the shift 
D) Including the date and time in each chart entry

Question 4

The nurse responds to a client's call light.When entering the room,the nurse sees that the client is lying on the floor,with the bed linens around his legs.Which of the following would be the most correctly written chart entry?

Accepted Answer

A) Recorder found client on floor; seems to have fallen out of bed by getting tangled in bed linens 
B) Client became tangled in the bed linens,then called for assistance after falling out of bed 
C) Recorder responded to client's call light; upon entering the room,found client on floor 
D) Client fell out of bed,but did push the call button for assistance 
A) Recorder found client on floor; seems to have fallen out of bed by getting tangled in bed linens 
B) Client became tangled in the bed linens,then called for assistance after falling out of bed 
C) Recorder responded to client's call light; upon entering the room,found client on floor 
D) Client fell out of bed,but did push the call button for assistance

Question 5

A client did not meet the goal of walking independently,without assistive devices,by discharge.The case manager,using a critical pathway,would identify this as which of the following?

Accepted Answer

A) An unattainable goal 
B) A variance 
C) An incorrectly written care plan 
D) An error in judgment on the case manager's part 
A) An unattainable goal 
B) A variance 
C) An incorrectly written care plan 
D) An error in judgment on the case manager's part

Question 6

A physician has called with a telephone order for one of her clients.What is the appropriate action by the registered nurse?

Accepted Answer

A) Write the order in the chart,and have the charge nurse co-sign it 
B) Copy the order onto the order sheet,then repeat the order back to the physician,indicating "TO" for telephone order 
C) Explain to the physician that a staff nurse cannot take the order but that the nurse will page the nursing supervisor 
D) Copy the order onto the physician's order sheet,and sign the physician's name,copying her handwriting as closely as possible 
A) Write the order in the chart,and have the charge nurse co-sign it 
B) Copy the order onto the order sheet,then repeat the order back to the physician,indicating "TO" for telephone order 
C) Explain to the physician that a staff nurse cannot take the order but that the nurse will page the nursing supervisor 
D) Copy the order onto the physician's order sheet,and sign the physician's name,copying her handwriting as closely as possible

Question 7

Mr.Suzuki,79,is deteriorating but remains alert and oriented.Three days after admission,he tells his nurse,"I am tired of being sick.I wish I could end it all." What is the most accurate and informative way to record this data in the progress notes?

Accepted Answer

A) Appears to be depressed,possibly suicidal 
B) Complains he is tired of being ill and wants to die 
C) Does not want to live any longer because he is tired of being ill 
D) Client states,"I am tired of being sick.I wish I could end it all." 
A) Appears to be depressed,possibly suicidal 
B) Complains he is tired of being ill and wants to die 
C) Does not want to live any longer because he is tired of being ill 
D) Client states,"I am tired of being sick.I wish I could end it all."

Exam 24: Documenting and Reporting

Under which category of SOAP charting would the nurse look to determine whether or not a client had reported having nausea?

A nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording.When searching for the most recent physician's orders,the nurse should look in which section?

Which of the following is a charting ERROR?

The nurse responds to a client's call light.When entering the room,the nurse sees that the client is lying on the floor,with the bed linens around his legs.Which of the following would be the most correctly written chart entry?

A client did not meet the goal of walking independently,without assistive devices,by discharge.The case manager,using a critical pathway,would identify this as which of the following?

A physician has called with a telephone order for one of her clients.What is the appropriate action by the registered nurse?

Mr.Suzuki,79,is deteriorating but remains alert and oriented.Three days after admission,he tells his nurse,"I am tired of being sick.I wish I could end it all." What is the most accurate and informative way to record this data in the progress notes?

Historical and Contemporary Nursing Practice

Nursing Education in Canada

Nursing Research in Canada

Nursing Philosophies, theories, concepts, frameworks, and Models

Values, ethics, and Advocacy

Accountability and Legal Aspects of Nursing

Health, wellness, and Illness

Health Promotion

The Canadian Health Care System

Environmental and Global Health Nursing

Safe Cultural Caring

Individual Care

Nursing Care of Families

Community Health Nursing

Rural and Remote Health Care

Complementary and Alternative Health Modalities

Concepts of Growth and Development

Development From Conception Through Adolescence

Young and Middle Adulthood

Older Adults

Critical Thinking

Caring and Communicating

The Nursing Process

Nursing Informatics and Technology

Teaching and Learning

Leading,managing,and Delegating

Health Assessment

Vital Signs

Pain Assessment and Management

Hygiene

Safety

Medications

Infection Prevention and Control

Skin Integrity and Wound Care

Caring for Perioperative Clients

Sensory Perception

Sleep

Activity and Exercise

Nutrition

Fecal Elimination

Urinary Elimination

Oxygenation and Circulation

Fluid,electrolyte,and Acid-Base Balance

Sexuality

Spirituality

Stress and Coping

Loss,grieving,and Death

Filters