Question 1

Which statement describes the best technique for identifying that a written error was made in a manual record sheet?

Accepted Answer

A)  Erase the incorrect statement and write the correct one. 
B)  Cross out the incorrect statement with a single line. 
C)  Cross out the wrong statement in a way that is not readable. 
D)  Use correction ink to mark the wrong statement. 
A)  Erase the incorrect statement and write the correct one. 
B)  Cross out the incorrect statement with a single line. 
C)  Cross out the wrong statement in a way that is not readable. 
D)  Use correction ink to mark the wrong statement. B

Question 2

What is the meaning of the abbreviation "Ungt"?

Accepted Answer

A)  It is not an acceptable abbreviation 
B)  Under the groin 
C)  Ointment 
D)  Undergarment 
A)  It is not an acceptable abbreviation 
B)  Under the groin 
C)  Ointment 
D)  Undergarment C

Question 3

Which is the correct abbreviation for before meals?

Accepted Answer

A)  AC 
B)  BM 
C)  IM 
D)  PC 
A)  AC 
B)  BM 
C)  IM 
D)  PC A

Question 4

Which document would be most helpful in determining the client's ability to perform activities of daily living?

Accepted Answer

A)  Medical information systems (MIS) 
B)  Medical administration record (MAR) 
C)  Resident assessment protocol (RAP) 
D)  Charting by exception (CB
E)  
A)  Medical information systems (MIS) 
B)  Medical administration record (MAR) 
C)  Resident assessment protocol (RAP) 
D)  Charting by exception (CB
E)

Question 5

A nurse is caring for a client who is having an extended recovery period. Which intervention would be most effective in improving care for this client?

Accepted Answer

A)  Review the client's health record. 
B)  Closely monitor the client's vital signs. 
C)  Interact more frequently with the client. 
D)  Identify simpler goals for the client. 
A)  Review the client's health record. 
B)  Closely monitor the client's vital signs. 
C)  Interact more frequently with the client. 
D)  Identify simpler goals for the client.

Question 6

The nurse has to document information to maintain the health record of the client. Which nursing action is required for each charting entry?

Accepted Answer

A)  Reporting each observation to the healthcare provider. 
B)  Signing the record with first initial, last name, and classification. 
C)  Obtaining a signature from the primary care provider. 
D)  Providing the day of the week on the entry. 
A)  Reporting each observation to the healthcare provider. 
B)  Signing the record with first initial, last name, and classification. 
C)  Obtaining a signature from the primary care provider. 
D)  Providing the day of the week on the entry.

Question 7

A nurse is caring for a client in a healthcare facility who is about to be transferred to another healthcare facility for specialized care. Which data would be most helpful to ensure continuity of care?

Accepted Answer

A)  Transfer notes summarizing care. 
B)  Referrals to community health services. 
C)  Short-term goals to be achieved. 
D)  Referrals to telephone consultation services. 
A)  Transfer notes summarizing care. 
B)  Referrals to community health services. 
C)  Short-term goals to be achieved. 
D)  Referrals to telephone consultation services.

Question 8

Which statement describes the purpose of progress records?

Accepted Answer

A)  Records all client information 
B)  Guides nurses in the development of individualized care plans 
C)  Provides access to the healthcare provider's orders and the nursing care plan 
D)  Describes the treatment and responses of the client 
A)  Records all client information 
B)  Guides nurses in the development of individualized care plans 
C)  Provides access to the healthcare provider's orders and the nursing care plan 
D)  Describes the treatment and responses of the client

Question 9

What client focused information should the nurse document in the client's manual health	 record?

Accepted Answer

A)  Long-term goals 
B)  Vital signs 
C)  Short-term goals 
D)  Weekly progress status 
A)  Long-term goals 
B)  Vital signs 
C)  Short-term goals 
D)  Weekly progress status

Question 10

Which is the primary goal for maintaining a healthcare record for the client in particular?

Accepted Answer

A)  Meeting established legal requirements 
B)  Documenting the ongoing health status of the client 
C)  Verifying data for quality assurance program evaluations 
D)  Providing information to be used as a resource for educational purposes 
A)  Meeting established legal requirements 
B)  Documenting the ongoing health status of the client 
C)  Verifying data for quality assurance program evaluations 
D)  Providing information to be used as a resource for educational purposes

Question 11

During a change of shift reporting, a nurse has to substitute for the nurse who was primarily responsible for the care of a client. Which process would be most effective for the nurse's change-of-shift reporting?

Accepted Answer

A)  Use the clinical care path as the guide. 
B)  Record any failure in achieving short-term goals. 
C)  Prepare a written summary for the oncoming nurse. 
D)  Report on specific nursing diagnosis. 
A)  Use the clinical care path as the guide. 
B)  Record any failure in achieving short-term goals. 
C)  Prepare a written summary for the oncoming nurse. 
D)  Report on specific nursing diagnosis.

Question 12

Which data entry systems are examples of focus charting? Select all that apply.

Accepted Answer

A)  SOAP 
B)  APIE 
C)  PIE 
D)  DARE 
E)  SOAPIER 
A)  SOAP 
B)  APIE 
C)  PIE 
D)  DARE 
E)  SOAPIER

Question 13

Which nursing interventions are helpful when considering the facility's need to be financially accountable? Select all that apply.

Accepted Answer

A)  Provide safe and effective healthcare to all clients. 
B)  Ensure that the facility meets the governmental standards of care. 
C)  Document all the treatments given to each client 
D)  Verify the use of special equipment required to provide safe client care 
E)  Record all billable services in the appropriate health records. 
A)  Provide safe and effective healthcare to all clients. 
B)  Ensure that the facility meets the governmental standards of care. 
C)  Document all the treatments given to each client 
D)  Verify the use of special equipment required to provide safe client care 
E)  Record all billable services in the appropriate health records.

Question 14

When considering documentation, what information should the nurse include on the client's MAR?

Accepted Answer

A)  Lists all the medications that the primary care provider has ordered for the client with spaces for the caregiver to mark when medications are given. 
B)  Documents large amount of information collected at intervals over a specified period of time in brief, concise entries. 
C)  At regular intervals, a summary of the client's condition or response to treatment is made. 
D)  Summarizes an account of a client's relationship with a healthcare facility. 
A)  Lists all the medications that the primary care provider has ordered for the client with spaces for the caregiver to mark when medications are given. 
B)  Documents large amount of information collected at intervals over a specified period of time in brief, concise entries. 
C)  At regular intervals, a summary of the client's condition or response to treatment is made. 
D)  Summarizes an account of a client's relationship with a healthcare facility.

Question 15

Which statement entered into the medical record by the nurse is both objective and descriptive while demonstrating the principles of documentation?

Accepted Answer

A)  Client lonely 
B)  Client out of touch with reality 
C)  Client in pain 
D)  Client rocking in chair 
A)  Client lonely 
B)  Client out of touch with reality 
C)  Client in pain 
D)  Client rocking in chair

Question 16

Why were apothecary units placed on the "do not use" list? Select all that apply.

Accepted Answer

A)  Misinterpreted because of similar abbreviations for multiple medications 
B)  Unfamiliar to many practitioners 
C)  Easily confused with metric units 
D)  Commonly mistaken for the number two 
E)  They are difficult to print 
A)  Misinterpreted because of similar abbreviations for multiple medications 
B)  Unfamiliar to many practitioners 
C)  Easily confused with metric units 
D)  Commonly mistaken for the number two 
E)  They are difficult to print

Question 17

Which type of note does the nurse enter into the medical record at regular intervals to summarize the client's condition or response to treatment?

Accepted Answer

A)  SOAP 
B)  Charting by exception 
C)  Progress 
D)  DARE 
A)  SOAP 
B)  Charting by exception 
C)  Progress 
D)  DARE

Question 18

The nurse is reviewing a chart updated using the charting by exception format. Where would the nurse find the client's most recent lung sounds?

Accepted Answer

A)  Narrative notes 
B)  Discipline area notes 
C)  Flow sheets 
D)  Problem-oriented list 
A)  Narrative notes 
B)  Discipline area notes 
C)  Flow sheets 
D)  Problem-oriented list

Question 19

What key guidelines are generally accepted for documentation of nursing care? Select all that apply.

Accepted Answer

A)  Document what should be done. 
B)  Documentation should be specific. 
C)  Use direct quotes in documentation whenever possible. 
D)  Documentation should be completed promptly. 
E)  Document what you see. 
A)  Document what should be done. 
B)  Documentation should be specific. 
C)  Use direct quotes in documentation whenever possible. 
D)  Documentation should be completed promptly. 
E)  Document what you see.

Question 20

Which statement accurately describes aspects of computerized charting?

Accepted Answer

A)  The system is relatively inexpensive to maintain. 
B)  Bedside terminals eliminate the use of flow sheets and manual notes. 
C)  The system provides speed and convenience for both entering and retrieving information. 
D)  The system better protects client privacy than does conventional charting and storage methods. 
A)  The system is relatively inexpensive to maintain. 
B)  Bedside terminals eliminate the use of flow sheets and manual notes. 
C)  The system provides speed and convenience for both entering and retrieving information. 
D)  The system better protects client privacy than does conventional charting and storage methods.

Exam 37: Documenting and Reporting

Which statement describes the best technique for identifying that a written error was made in a manual record sheet?

What is the meaning of the abbreviation "Ungt"?

Which is the correct abbreviation for before meals?

Which document would be most helpful in determining the client's ability to perform activities of daily living?

A nurse is caring for a client who is having an extended recovery period. Which intervention would be most effective in improving care for this client?

The nurse has to document information to maintain the health record of the client. Which nursing action is required for each charting entry?

A nurse is caring for a client in a healthcare facility who is about to be transferred to another healthcare facility for specialized care. Which data would be most helpful to ensure continuity of care?

Which statement describes the purpose of progress records?

What client focused information should the nurse document in the client's manual health record?

Which is the primary goal for maintaining a healthcare record for the client in particular?

During a change of shift reporting, a nurse has to substitute for the nurse who was primarily responsible for the care of a client. Which process would be most effective for the nurse's change-of-shift reporting?

Which data entry systems are examples of focus charting? Select all that apply.

Which nursing interventions are helpful when considering the facility's need to be financially accountable? Select all that apply.

When considering documentation, what information should the nurse include on the client's MAR?

Which statement entered into the medical record by the nurse is both objective and descriptive while demonstrating the principles of documentation?

Why were apothecary units placed on the "do not use" list? Select all that apply.

Which type of note does the nurse enter into the medical record at regular intervals to summarize the client's condition or response to treatment?

The nurse is reviewing a chart updated using the charting by exception format. Where would the nurse find the client's most recent lung sounds?

What key guidelines are generally accepted for documentation of nursing care? Select all that apply.

Which statement accurately describes aspects of computerized charting?

The Origins of Nursing

Beginning Your Nursing Career

The Healthcare Delivery System

Legal and Ethical Aspects of Nursing

Basic Human Needs

Health and Wellness

Community Health

Transcultural Healthcare

The Family

Infancy and Childhood

Adolescence

Early and Middle Adulthood

Older Adulthood and Aging

Death and Dying

Organization of the Human Body

The Integumentary System

Fluid and Electrolyte Balance

The Musculoskeletal System

The Nervous System

The Endocrine System

The Sensory System

The Cardiovascular System

The Hematologic and Lymphatic Systems

The Immune System

The Respiratory System

The Digestive System

The Urinary System

The Male Reproductive System

The Female Reproductive System

Basic Nutrition

Transcultural and Social Aspects of Nutrition

Diet Therapy and Special Diets

Introduction to the Nursing Process

Nursing Assessment

Nursing Diagnosis and Planning

Implementing and Evaluating Care

The Healthcare Facility Environment

Emergency Preparedness

Introduction to Microbiology

Medical Asepsis

Infection Control

Emergency Care and First Aid

Therapeutic Communication Skills

Admission, Transfer, and Discharge

Vital Signs

Data Collection in Client Care

Body Mechanics and Positioning

Beds and Bed Making

Personal Hygiene and Skin Care

Elimination

Specimen Collection

Bandages and Binders

Heat and Cold Applications

Client Comfort and Pain Management

Preoperative and Postoperative Care

Surgical Asepsis

Wound Care

End-Of-Life Care

Review of Mathematics