Question 1

The method of computer-assisted charting: (Select all that apply.)

Accepted Answer

A)  improves communication between departments. 
B)  is less costly to educate personnel to the method. 
C)  speeds reimbursement for services. 
D)  allows electronic records to be retrieved more quickly. 
E)  allows entries to be made at point of care. 
A)  improves communication between departments. 
B)  is less costly to educate personnel to the method. 
C)  speeds reimbursement for services. 
D)  allows electronic records to be retrieved more quickly. 
E)  allows entries to be made at point of care. A, C, D, E

Question 2

A nurse enters a notation in a patient's chart but then discovers that the notation was made in the wrong chart. The nurse correctly:

Accepted Answer

A)  draws a single line through the notation so that it is still readable and writes "mistaken entry," his signature, and the date and time. 
B)  removes the page on which the error is written and rewrites the other correct notes. 
C)  blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time. 
D)  whites out the wrong entry and writes the note in the chart of the correct patient. 
A)  draws a single line through the notation so that it is still readable and writes "mistaken entry," his signature, and the date and time. 
B)  removes the page on which the error is written and rewrites the other correct notes. 
C)  blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time. 
D)  whites out the wrong entry and writes the note in the chart of the correct patient. A

Question 3

A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:

Accepted Answer

A)  nurse is actively promoting nursing as a profession, and it is important to share information that might encourage others to pursue a nursing career. 
B)  actions of the nurse are appropriate since his neighbor is his confidante, and the neighbor has assured him the information provided will not be shared. 
C)  nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor. 
D)  nurse has not violated the confidentiality of the patient because the patient is terminal; sharing this information will not harm the patient. 
A)  nurse is actively promoting nursing as a profession, and it is important to share information that might encourage others to pursue a nursing career. 
B)  actions of the nurse are appropriate since his neighbor is his confidante, and the neighbor has assured him the information provided will not be shared. 
C)  nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor. 
D)  nurse has not violated the confidentiality of the patient because the patient is terminal; sharing this information will not harm the patient. C

Question 4

The nurse uses the flow sheet in patient care documentation primarily:

Accepted Answer

A)  to track routine assessments, treatments, and frequently given care. 
B)  to eliminate written narratives and to save time. 
C)  in computer-assisted charting to create visual graphs showing change. 
D)  to improve continuity of care and exchange of information among disciplines. 
A)  to track routine assessments, treatments, and frequently given care. 
B)  to eliminate written narratives and to save time. 
C)  in computer-assisted charting to create visual graphs showing change. 
D)  to improve continuity of care and exchange of information among disciplines.

Question 5

A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:

Accepted Answer

A)  motivated to learn about the health problem of this patient and is appropriately seeking knowledge during his clinical experience. 
B)  doing appropriate research about nursing care as long as information is not divulged. 
C)  violating the confidentiality of the patient's record. 
D)  neglecting the assigned patient load and should read the unassigned patient's chart only after his assigned work is completed. 
A)  motivated to learn about the health problem of this patient and is appropriately seeking knowledge during his clinical experience. 
B)  doing appropriate research about nursing care as long as information is not divulged. 
C)  violating the confidentiality of the patient's record. 
D)  neglecting the assigned patient load and should read the unassigned patient's chart only after his assigned work is completed.

Question 6

A nurse understands that the physician's directives for patient care are also referred to as the:

Accepted Answer

A)  history and physical. 
B)  physician's orders. 
C)  progress notes. 
D)  face sheet. 
A)  history and physical. 
B)  physician's orders. 
C)  progress notes. 
D)  face sheet.

Question 7

Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

Accepted Answer

A)  "4 cm reddened area over sacrum. Skin intact, warm, and dry." 
B)  "Taking fluids poorly, but more than yesterday." 
C)  "Apparently comfortable all night. Offers no complaints of pain." 
D)  "Patient says she is still slightly nauseated, would like to try some toast and tea." 
A)  "4 cm reddened area over sacrum. Skin intact, warm, and dry." 
B)  "Taking fluids poorly, but more than yesterday." 
C)  "Apparently comfortable all night. Offers no complaints of pain." 
D)  "Patient says she is still slightly nauseated, would like to try some toast and tea."

Question 8

A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:

Accepted Answer

A)  at the end of the shift so that the nurse can give his full attention and time to the patient's needs during the shift. 
B)  a nursing care plan in the chart before assessing the patient so that the nurse can identify priorities. 
C)  at least three times during the shift: at the beginning, in the middle, at the end, and as needed. 
D)  an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift. 
A)  at the end of the shift so that the nurse can give his full attention and time to the patient's needs during the shift. 
B)  a nursing care plan in the chart before assessing the patient so that the nurse can identify priorities. 
C)  at least three times during the shift: at the beginning, in the middle, at the end, and as needed. 
D)  an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.

Question 9

In a skilled nursing facility, if all of the following are available, the best way for the new nurse to obtain current information about the needs and abilities of his patients would be to use the:

Accepted Answer

A)  physician's order sheets. 
B)  nurse's admission history and physical. 
C)  nursing Kardex. 
D)  most recent nurse's notes. 
A)  physician's order sheets. 
B)  nurse's admission history and physical. 
C)  nursing Kardex. 
D)  most recent nurse's notes.

Question 10

If an agency is using computer-assisted charting, the nurse is responsible for:

Accepted Answer

A)  learning the passwords of the staff nurses and physicians so that they can communicate with one another. 
B)  guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal. 
C)  teaching the patient to input information about herself, such as intake and output or symptoms the patient may experience. 
D)  choosing whether he will use the computer to help in charting or continue to use traditional paper documentation. 
A)  learning the passwords of the staff nurses and physicians so that they can communicate with one another. 
B)  guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal. 
C)  teaching the patient to input information about herself, such as intake and output or symptoms the patient may experience. 
D)  choosing whether he will use the computer to help in charting or continue to use traditional paper documentation.

Question 11

Helpful cultural information the nurse should include on the admission note is: (Select all that apply.)

Accepted Answer

A)  primary language spoken. 
B)  number of children in the immediate household. 
C)  beliefs about causality of illness. 
D)  level of English literacy. 
E)  dietary concerns. 
A)  primary language spoken. 
B)  number of children in the immediate household. 
C)  beliefs about causality of illness. 
D)  level of English literacy. 
E)  dietary concerns.

Question 12

A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests." When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:

Accepted Answer

A)  "Refuses to have blood drawn. Doctor notified." 
B)  "Refuses to have blood drawn; says tests are 'useless.' Doctor notified." 
C)  "Doctor notified of failure to draw ordered blood work." 
D)  "Blood not drawn because tests are no longer desired by patient." 
A)  "Refuses to have blood drawn. Doctor notified." 
B)  "Refuses to have blood drawn; says tests are 'useless.' Doctor notified." 
C)  "Doctor notified of failure to draw ordered blood work." 
D)  "Blood not drawn because tests are no longer desired by patient."

Question 13

The Quality and Safety Education for Nurses (QSEN) project has identified the most important pre-licensing skills for nurses as:

Accepted Answer

A)  effective communication. 
B)  informatics. 
C)  familiarity with medical terms. 
D)  writing nursing care plans. 
A)  effective communication. 
B)  informatics. 
C)  familiarity with medical terms. 
D)  writing nursing care plans.

Question 14

Advantages of the problem-oriented medical record (POMR) are that this method of charting: (Select all that apply.)

Accepted Answer

A)  promotes the problem-solving approach. 
B)  formats charting into chronological order. 
C)  makes tracking trends in patient care easy. 
D)  allows for easy auditing of patient records to evaluate staff performance. 
E)  reinforces application of the nursing process. 
A)  promotes the problem-solving approach. 
B)  formats charting into chronological order. 
C)  makes tracking trends in patient care easy. 
D)  allows for easy auditing of patient records to evaluate staff performance. 
E)  reinforces application of the nursing process.

Question 15

When using a case management system of charting a(n) __________, an unexpected event in the patient's condition is documented on the back of the pathway sheets.

Accepted Answer

variance
A variance is an unex

Question 16

Health care professionals assigned to a patient require access to the chart to review information and to document care given. All contents of the chart must be kept ________. The contents of the chart should not be discussed with persons who are not involved in the care of the patient.

Accepted Answer

confidential
The nur

Question 17

Advantages of source-oriented or narrative charting include all of the following except that it:

Accepted Answer

A)  encourages documentation of normal and abnormal findings. 
B)  gives information on the patient's condition and care in chronological order. 
C)  indicates the patient's baseline condition for each shift. 
D)  includes aspects of all steps of the nursing process. 
A)  encourages documentation of normal and abnormal findings. 
B)  gives information on the patient's condition and care in chronological order. 
C)  indicates the patient's baseline condition for each shift. 
D)  includes aspects of all steps of the nursing process.

Question 18

The nurse with a patient who complains of severe pain documents every 15 minutes about the steps taken to try to relieve the pain (without success). The nurse also documents the time and content of two calls made to the patient's physician requesting that the physician examine the patient for unexpected complications. This documentation by the nurse is likely to:

Accepted Answer

A)  cause the physician to come to the attention of the hospital administration. 
B)  be questioned by the nurse's supervisor for time inefficiency. 
C)  be used against the nurse if a lawsuit results, because it proves the nurse was not able to relieve the pain. 
D)  justify insurance reimbursement for an extended duration of hospitalization for the patient. 
A)  cause the physician to come to the attention of the hospital administration. 
B)  be questioned by the nurse's supervisor for time inefficiency. 
C)  be used against the nurse if a lawsuit results, because it proves the nurse was not able to relieve the pain. 
D)  justify insurance reimbursement for an extended duration of hospitalization for the patient.

Question 19

Which examples of documentation would be most informative to transcribe to the patient's medical record?

Accepted Answer

A)  "Patient consumed two slices of bread and a cup of coffee at breakfast." 
B)  "Patient does not appear to be hungry after consuming breakfast." 
C)  "Patient ate a small amount of bread and drank a little coffee for breakfast." 
D)  "Patient ate well for breakfast, lunch, and dinner and seems content." 
A)  "Patient consumed two slices of bread and a cup of coffee at breakfast." 
B)  "Patient does not appear to be hungry after consuming breakfast." 
C)  "Patient ate a small amount of bread and drank a little coffee for breakfast." 
D)  "Patient ate well for breakfast, lunch, and dinner and seems content."

Question 20

In a chart for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse charts "Subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge." This type of charting is an example of:

Accepted Answer

A)  charting by exception. 
B)  narrative style. 
C)  a problem-oriented medical record (POMR). 
D)  the case management system. 
A)  charting by exception. 
B)  narrative style. 
C)  a problem-oriented medical record (POMR). 
D)  the case management system.

Exam 7: Documentation of Nursing Care

The method of computer-assisted charting: (Select all that apply.)

A nurse enters a notation in a patient's chart but then discovers that the notation was made in the wrong chart. The nurse correctly:

A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:

The nurse uses the flow sheet in patient care documentation primarily:

A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:

A nurse understands that the physician's directives for patient care are also referred to as the:

Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:

In a skilled nursing facility, if all of the following are available, the best way for the new nurse to obtain current information about the needs and abilities of his patients would be to use the:

If an agency is using computer-assisted charting, the nurse is responsible for:

Helpful cultural information the nurse should include on the admission note is: (Select all that apply.)

The Quality and Safety Education for Nurses (QSEN) project has identified the most important pre-licensing skills for nurses as:

Advantages of the problem-oriented medical record (POMR) are that this method of charting: (Select all that apply.)

When using a case management system of charting a(n) __________, an unexpected event in the patient's condition is documented on the back of the pathway sheets.

Health care professionals assigned to a patient require access to the chart to review information and to document care given. All contents of the chart must be kept ________. The contents of the chart should not be discussed with persons who are not involved in the care of the patient.

Advantages of source-oriented or narrative charting include all of the following except that it:

Which examples of documentation would be most informative to transcribe to the patient's medical record?

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

Nursing Process and Critical Thinking

Assessment, Nursing Diagnosis, and Planning

Implementation and Evaluation

Communication and the Nurse-Patient Relationship

Patient Teaching for Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, the Dying Patient, and Palliative Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Lifting, Moving, and Positioning Patients

Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Patient Environment and Safety

Measuring Vital Signs

Assessing Health Status

Admitting, Transferring, and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid–Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Diet Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain, Comfort, and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Elderly

Common Psychosocial Care Problems of the Elderly

Filters