Question 1

Prior to preparing to administer medications to the patient, the nurse should compare the provider orders with what document?

Accepted Answer

A)  Flow sheet 
B)  Kardex 
C)  MAR 
D)  Admission summary 
A)  Flow sheet 
B)  Kardex 
C)  MAR 
D)  Admission summary C

Question 2

The nurse knows that the Health Insurance Portability and Accountability Act (HIPAA) allows health information to be shared in which circumstances?

Accepted Answer

A)  To provide treatment for the patient 
B)  To determine billing and payment issues 
C)  To enhance health care operations related to the patient 
D)  In public areas such as the cafeteria or elevator 
E)  Over the telephone with any family member 
A)  To provide treatment for the patient 
B)  To determine billing and payment issues 
C)  To enhance health care operations related to the patient 
D)  In public areas such as the cafeteria or elevator 
E)  Over the telephone with any family member A, B, C

Question 3

What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation?

Accepted Answer

A)  They are chronologic. 
B)  They are examples of problem-oriented charting. 
C)  They are narrative charting. 
D)  They are forms of "charting by exception." 
A)  They are chronologic. 
B)  They are examples of problem-oriented charting. 
C)  They are narrative charting. 
D)  They are forms of "charting by exception." B

Question 4

The nursing instructor teaching students about charting explains that this type of charting records only abnormal or significant data?

Accepted Answer

A)  PIE 
B)  SOAP 
C)  Narrative 
D)  Charting by exception 
A)  PIE 
B)  SOAP 
C)  Narrative 
D)  Charting by exception

Question 5

The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. What is the best central location for the nurse to obtain this information?

Accepted Answer

A)  Admission summary 
B)  Discharge summary 
C)  Flow sheet 
D)  Kardex 
A)  Admission summary 
B)  Discharge summary 
C)  Flow sheet 
D)  Kardex

Question 6

The nursing student is learning about SBAR reporting. What statements about the patient are matched with the correct part of the report?

Accepted Answer

A)  Patient is an 84-year-old female with a history of hypertension: S 
B)  Patient's blood pressure has dropped from 142/92 to 98/48 mmHg: S 
C)  Patient is hemorrhaging with four saturated dressings in an hour: A 
D)  The patient took an overdose of antidepressants three days ago: B 
E)  By policy, the patient needs transferred to the ICU; please come write the orders: R 
A)  Patient is an 84-year-old female with a history of hypertension: S 
B)  Patient's blood pressure has dropped from 142/92 to 98/48 mmHg: S 
C)  Patient is hemorrhaging with four saturated dressings in an hour: A 
D)  The patient took an overdose of antidepressants three days ago: B 
E)  By policy, the patient needs transferred to the ICU; please come write the orders: R

Question 7

The nurse identifies which components to be expected nursing documentation?

Accepted Answer

A)  Nursing assessment 
B)  The care plan 
C)  Critique of the physician's care 
D)  Interventions 
E)  Patient responses to care 
A)  Nursing assessment 
B)  The care plan 
C)  Critique of the physician's care 
D)  Interventions 
E)  Patient responses to care

Question 8

The nurse identifies which statement to be true regarding nursing documentation?

Accepted Answer

A)  Standards for documentation are established by a national commission. 
B)  Medical records should be accessible to everyone. 
C)  Documentation should not include the patient's diagnosis. 
D)  High-quality nursing documentation reflects the nursing process. 
A)  Standards for documentation are established by a national commission. 
B)  Medical records should be accessible to everyone. 
C)  Documentation should not include the patient's diagnosis. 
D)  High-quality nursing documentation reflects the nursing process.

Question 9

When the nurse is charting in the paper medical record, what action does the nurse carry out?

Accepted Answer

A)  Print his/her name since signatures are often not readable. 
B)  Omit nursing credentials since only the nurses chart 
C)  Skip a line between entries so that it looks neat. 
D)  Use black ink unless the facility allows a different color. 
A)  Print his/her name since signatures are often not readable. 
B)  Omit nursing credentials since only the nurses chart 
C)  Skip a line between entries so that it looks neat. 
D)  Use black ink unless the facility allows a different color.

Question 10

The nurse recognizes that nursing documentation is guided by what process?

Accepted Answer

A)  The nursing process 
B)  NANDA-I, nursing diagnoses 
C)  Nursing interventions classification 
D)  Nursing Outcomes Classification 
A)  The nursing process 
B)  NANDA-I, nursing diagnoses 
C)  Nursing interventions classification 
D)  Nursing Outcomes Classification

Question 11

When charting is done using the DAR charting format, the nurse documents which components?

Accepted Answer

A)  The patient problems 
B)  Subjective data 
C)  Any actions initiated 
D)  Objective data 
E)  The patient's response to interventions 
A)  The patient problems 
B)  Subjective data 
C)  Any actions initiated 
D)  Objective data 
E)  The patient's response to interventions

Question 12

The nurse understands the use of standardized language in care planning is beneficial for what reasons?

Accepted Answer

A)  Standardized language provides consistency. 
B)  Standardized language improves communication among nurses. 
C)  Standardized language increases the visibility of nursing interventions. 
D)  Standardized language enhances data collection. Standardized language supports adherence to care standards. 
E)  None of above 
A)  Standardized language provides consistency. 
B)  Standardized language improves communication among nurses. 
C)  Standardized language increases the visibility of nursing interventions. 
D)  Standardized language enhances data collection. Standardized language supports adherence to care standards. 
E)  None of above

Question 13

The nurse identifies which true statement regarding the medical record?

Accepted Answer

A)  It serves as a major communication tool but is not a legal document. 
B)  It cannot be used to assess quality of care issues. 
C)  It is not used to determine reimbursement claims. 
D)  It can be used as a tool for biomedical research and provide education. 
A)  It serves as a major communication tool but is not a legal document. 
B)  It cannot be used to assess quality of care issues. 
C)  It is not used to determine reimbursement claims. 
D)  It can be used as a tool for biomedical research and provide education.

Question 14

The nurse recognizes which statement to be accurate regarding what should be documented?

Accepted Answer

A)  Document facts and subjective data from the patient. 
B)  Document how he/she feels about the care being provided. 
C)  Document in a "block" fashion once per shift. 
D)  Double document as often as possible in order to not miss anything. 
A)  Document facts and subjective data from the patient. 
B)  Document how he/she feels about the care being provided. 
C)  Document in a "block" fashion once per shift. 
D)  Double document as often as possible in order to not miss anything.

Question 15

The nurse is admitting a patient who has had several previous admissions. To obtain a knowledge base about the patient's medical history, the nurse would access which document?

Accepted Answer

A)  Electronic medical record (EMR) 
B)  The computerized provider order entry (CPO
E)  
C)  Electronic health record (EHR) 
D)  Primary provider's office notes 
A)  Electronic medical record (EMR) 
B)  The computerized provider order entry (CPO
E)  
C)  Electronic health record (EHR) 
D)  Primary provider's office notes

Question 16

The nurse is caring for patients on a unit that uses electronic health records (EHRs). What action by the nurse protects personal health information?

Accepted Answer

A)  The nurse should allow only nurses that he/she knows and trusts to use his/her verification code. 
B)  The nurse should not worry about mistakes since the information cannot be tracked. 
C)  The nurse should never share any password with anyone. 
D)  The nurse should be aware that the EHR is sophisticated and immune to failure. 
A)  The nurse should allow only nurses that he/she knows and trusts to use his/her verification code. 
B)  The nurse should not worry about mistakes since the information cannot be tracked. 
C)  The nurse should never share any password with anyone. 
D)  The nurse should be aware that the EHR is sophisticated and immune to failure.

Question 17

The nurse knows that paper records are being replaced by other forms of record keeping for what reason?

Accepted Answer

A)  Paper is fragile and susceptible to damage. 
B)  Paper records are always available to multiple people at a time. 
C)  Paper records can be stored without difficulty and are easily retrievable. 
D)  Paper records are permanent and last indefinitely. 
A)  Paper is fragile and susceptible to damage. 
B)  Paper records are always available to multiple people at a time. 
C)  Paper records can be stored without difficulty and are easily retrievable. 
D)  Paper records are permanent and last indefinitely.

Question 18

What fact is the nurse aware of when charting using electronic documentation?

Accepted Answer

A)  Errors can be corrected and totally removed from the record in the screen view. 
B)  Log-on access to the electronic record identifies the person charting. 
C)  Each entry requires the nurse to sign her/his name and credentials. 
D)  Documenting significant changes in the electronic record ends the nurse's responsibility. 
A)  Errors can be corrected and totally removed from the record in the screen view. 
B)  Log-on access to the electronic record identifies the person charting. 
C)  Each entry requires the nurse to sign her/his name and credentials. 
D)  Documenting significant changes in the electronic record ends the nurse's responsibility.

Question 19

What action should the nurse take to correct an error in paper charting?

Accepted Answer

A)  Remove the sheet with the error and replace it with a new sheet with the correct entry. 
B)  Scribble out the error and rewrite the entry correctly. 
C)  Draw a single line through the error write "error" above or after the entry, along with the nurse's initials. 
D)  Leave the entry as is and tell the charge nurse. 
A)  Remove the sheet with the error and replace it with a new sheet with the correct entry. 
B)  Scribble out the error and rewrite the entry correctly. 
C)  Draw a single line through the error write "error" above or after the entry, along with the nurse's initials. 
D)  Leave the entry as is and tell the charge nurse.

Question 20

The nurse understands the need for accurate documentation due to which fact?

Accepted Answer

A)  Accurate documentation is needed for proper reimbursement. 
B)  Accurate documentation must be electronically generated. 
C)  Accurate documentation does not include e-mails or faxes. 
D)  Accurate documentation is only accepted in court if written by hand. 
A)  Accurate documentation is needed for proper reimbursement. 
B)  Accurate documentation must be electronically generated. 
C)  Accurate documentation does not include e-mails or faxes. 
D)  Accurate documentation is only accepted in court if written by hand.

Exam 10: Documentation, Electronic Health Records, and Reporting

Prior to preparing to administer medications to the patient, the nurse should compare the provider orders with what document?

The nurse knows that the Health Insurance Portability and Accountability Act (HIPAA) allows health information to be shared in which circumstances?

What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation?

The nursing instructor teaching students about charting explains that this type of charting records only abnormal or significant data?

The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. What is the best central location for the nurse to obtain this information?

The nursing student is learning about SBAR reporting. What statements about the patient are matched with the correct part of the report?

The nurse identifies which components to be expected nursing documentation?

The nurse identifies which statement to be true regarding nursing documentation?

When the nurse is charting in the paper medical record, what action does the nurse carry out?

The nurse recognizes that nursing documentation is guided by what process?

When charting is done using the DAR charting format, the nurse documents which components?

The nurse understands the use of standardized language in care planning is beneficial for what reasons?

The nurse identifies which true statement regarding the medical record?

The nurse recognizes which statement to be accurate regarding what should be documented?

The nurse is admitting a patient who has had several previous admissions. To obtain a knowledge base about the patient's medical history, the nurse would access which document?

The nurse is caring for patients on a unit that uses electronic health records (EHRs). What action by the nurse protects personal health information?

The nurse knows that paper records are being replaced by other forms of record keeping for what reason?

What fact is the nurse aware of when charting using electronic documentation?

What action should the nurse take to correct an error in paper charting?

The nurse understands the need for accurate documentation due to which fact?

Nursing, Theory, and Professional Practice

Values, Beliefs, and Caring

Communication

Critical Thinking in Nursing

Introduction to the Nursing Process

Assessment

Nursing Diagnosis

Planning

Implementation and Evaluation

Ethical and Legal Considerations

Leadership and Management

Evidence-Based Practice and Nursing Research

Health Literacy and Patient Education

Nursing Informatics

Health and Wellness

Human Development: Conception Through Adolescence

Human Development: Young Adult Through Older Adult

Vital Signs

Health History and Physical Assessment

Ethnicity and Cultural Assessment

Spiritual Health

Public Health, Community-Based, and Home Health Care

Human Sexuality

Safety

Asepsis and Infection Control

Hygiene and Personal Care

Activity, Immobility, and Safe Movement

Skin Integrity and Wound Care

Nutrition

Cognitive and Sensory Alterations

Stress and Coping

Sleep

Diagnostic Testing

Medication Administration

Pain Management

Perioperative Nursing Care

Oxygenation and Tissue Perfusion

Fluid, Electrolytes, and Acid-Base Balance

Bowel Elimination

Urinary Elimination

Death and Loss

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