Question 1

After providing care,a nurse charts in the patient's record.Which entry should the nurse document?

Accepted Answer

A) "Appears restless when sitting in the chair" 
B) "Drank adequate amounts of water" 
C) "Apparently is asleep with eyes closed" 
D) "Skin pale and cool" 
A) "Appears restless when sitting in the chair" 
B) "Drank adequate amounts of water" 
C) "Apparently is asleep with eyes closed" 
D) "Skin pale and cool"

Question 2

A hospital is using computer software that allows all health care providers to use a protocol system to document the care they provide.Which type of system/design will the nurse be using?

Accepted Answer

A) Clinical decision support system. 
B) Nursing process design. 
C) Critical pathway design. 
D) Computerized provider order entry system. 
A) Clinical decision support system. 
B) Nursing process design. 
C) Critical pathway design. 
D) Computerized provider order entry system.

Question 3

A nurse developed the following discharge summary sheet.Which critical information should be added?
TOPIC: DISCHARGE SUMMARY
Medication
Diet
Activity level
Follow-up care
Wound care
Phone numbers
When to call the doctor
Time of discharge

Accepted Answer

A) Kardex form 
B) Admission nursing history 
C) Mode of transportation 
D) SOAP notes 
A) Kardex form 
B) Admission nursing history 
C) Mode of transportation 
D) SOAP notes

Question 4

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a productive cough.When is the best time for the nurse to start discharge planning for this patient?

Accepted Answer

A) Upon admission. 
B) Right before discharge. 
C) After the congestion is treated. 
D) When the primary care provider writes the order. 
A) Upon admission. 
B) Right before discharge. 
C) After the congestion is treated. 
D) When the primary care provider writes the order.

Question 5

A nurse records the following: "Patient is wheezing and experiencing some dyspnea on exertion." This represents which of the following?

Accepted Answer

A) The "S" in SOAP documentation. 
B) Focus documentation. 
C) The "P" of PIE documentation. 
D) The "R" in DAR documentation. 
A) The "S" in SOAP documentation. 
B) Focus documentation. 
C) The "P" of PIE documentation. 
D) The "R" in DAR documentation.

Question 6

Identify the purposes of a health care record.(Select all that apply. )

Accepted Answer

A) Communication. 
B) Legal documentation. 
C) Reimbursement. 
D) Education. 
E) Research.
F)Nursing process. 
A) Communication. 
B) Legal documentation. 
C) Reimbursement. 
D) Education. 
E) Research.
F)Nursing process.

Question 7

Which situation best indicates that the nurse has a good understanding of auditing and monitoring patients' health records?

Accepted Answer

A) The nurse determines the degree to which standards of care are met by reviewing patients' health records. 
B) The nurse realizes that care not documented in patients' health records still qualifies as care provided. 
C) The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. 
D) The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment. 
A) The nurse determines the degree to which standards of care are met by reviewing patients' health records. 
B) The nurse realizes that care not documented in patients' health records still qualifies as care provided. 
C) The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. 
D) The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment.

Question 8

A nurse has provided care to a patient.Which entry should the nurse document in the patient's record?

Accepted Answer

A) "Patient seems to be in pain and states,'I feel uncomfortable.'" 
B) "Status unchanged,doing well." 
C) "Left abdominal incision 5 cm in length without redness,drainage,or edema." 
D) "Patient is hard to care for and refuses all treatments and medications.Family present." 
A) "Patient seems to be in pain and states,'I feel uncomfortable.'" 
B) "Status unchanged,doing well." 
C) "Left abdominal incision 5 cm in length without redness,drainage,or edema." 
D) "Patient is hard to care for and refuses all treatments and medications.Family present."

Question 9

A nurse is creating a plan to reduce data entry errors and maintain confidentiality.Which guidelines should the nurse include? (Select all that apply. )

Accepted Answer

A) Create a password with just letters. 
B) Bypass the firewall. 
C) Use a programmed speed-dial key when faxing. 
D) Implement an automatic sign-off. 
E) Impose disciplinary actions for inappropriate access.
F)Shred papers containing personal health information. 
A) Create a password with just letters. 
B) Bypass the firewall. 
C) Use a programmed speed-dial key when faxing. 
D) Implement an automatic sign-off. 
E) Impose disciplinary actions for inappropriate access.
F)Shred papers containing personal health information.

Question 10

A nurse is preparing a change-of-shift report for a patient who had chest pain.Which information is critical for the nurse to include?

Accepted Answer

A) "Pupils equal and reactive to light." 
B) "The family is a 'pain.'" 
C) "Had poor results from the pain medication." 
D) "Sharp pain of 8 on a scale of 1 to 10." 
A) "Pupils equal and reactive to light." 
B) "The family is a 'pain.'" 
C) "Had poor results from the pain medication." 
D) "Sharp pain of 8 on a scale of 1 to 10."

Exam 15: Documenting and Reporting

After providing care,a nurse charts in the patient's record.Which entry should the nurse document?

A hospital is using computer software that allows all health care providers to use a protocol system to document the care they provide.Which type of system/design will the nurse be using?

A nurse developed the following discharge summary sheet.Which critical information should be added? TOPIC: DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a productive cough.When is the best time for the nurse to start discharge planning for this patient?

A nurse records the following: "Patient is wheezing and experiencing some dyspnea on exertion." This represents which of the following?

Identify the purposes of a health care record.(Select all that apply. )

Which situation best indicates that the nurse has a good understanding of auditing and monitoring patients' health records?

A nurse has provided care to a patient.Which entry should the nurse document in the patient's record?

A nurse is creating a plan to reduce data entry errors and maintain confidentiality.Which guidelines should the nurse include? (Select all that apply. )

A nurse is preparing a change-of-shift report for a patient who had chest pain.Which information is critical for the nurse to include?

Health and Wellness

The Canadian Health Care Delivery System

The Development of Nursing in Canada

Community Health Nursing Practice

Theoretical Foundations of Nursing Practice

Evidence-Informed Practice

Nursing Values and Ethics

Legal Implications in Nursing Practice

Global Health

Indigenous Health

Nursing Leadership, management, and Collaborative Practice

Critical Thinking in Nursing Practice

Nursing Assessment, diagnosis, and Planning

Implementing and Evaluating Nursing Care

Nursing Informatics and Canadian Nursing Practice

Communication and Relational Practice

Patient-Centred Care: Interprofessional Collaborative Practice

Family Nursing

Patient Education

Developmental Theories

Conception Through Adolescence

Young to Middle Adulthood

Older Persons

The Experience of Loss, death, and Grief

Self-Concept

Sexuality

Spirituality in Health and Health Care

Stress and Adaptation

Vital Signs

Pain Assessment and Management

Health Assessment and Physical Examination

Infection Control

Medication Administration

Complementary and Alternative Approaches in Health Care

Activity and Exercise

Quality and Patient Safety

Hygiene

Cardiopulmonary Functioning and Oxygenation

Fluid, electrolyte, and Acid-base Balances

Sleep

Nutrition

Urinary Elimination

Bowel Elimination

Mobility and Immobility

Skin Integrity and Wound Care

Sensory Alterations

Care of Surgical Patients

Filters