Question 1

A nurse has taught the patient how to use crutches.The patient went up and down the stairs using crutches with no difficulties.Which information will the nurse use for the "I" in PIE charting?

Accepted Answer

A)  "Patient went up and down stairs."
B)  "Deficient knowledge regarding crutches."
C)  "Patient demonstrated use of crutches."
D)  "Patient used crutches with no difficulties." C

Question 2

A patient is being discharged home.Which information should the nurse include?

Accepted Answer

A)  Acuity level.
B)  Community resources.
C)  Standardized care plan.
D)  Kardex. B

Question 3

Which entry will require follow-up by the nurse manager?

Accepted Answer

A)  0800: Patient states,"Fell out of bed." Patient found lying by bed on the floor.Legs equal in length bilaterally with no distortion,pedal pulses strong,leg strength equal and strong,no bruising or bleeding.Neuro checks within normal limits.States,"Did not pass out." Assisted back to bed.Call bell within reach.Bed monitor on.-------------------Jane More,RN
B)  0810: Notified primary care provider of patient's status.New orders received.-------------------Jane More,RN
C)  0815: Portable x-ray of L hip taken in room.Patient states,"I feel fine."-------------------Jane More,RN
D)  0830: Incident report completed and placed on chart.-------------------Jane More,RN D

Question 4

A nurse is using the source record and wants to find the patient's daily weights.Where should the nurse look?

Accepted Answer

A)  Database.
B)  Medical history and examination.
C)  Progress notes.
D)  Graphic sheet and flow sheet.

Question 5

According to documentation guidelines the most appropriate notation is

Accepted Answer

A)  "1230 hours: Patient's vital signs taken."
B)  "0700 hours: Patient drank adequate amount of fluids."
C)  "0900 hours: Morphine given for lower abdominal pain."
D)  "0830 hours: Increased IV fluid rate to 100 mL per hour."

Question 6

Which situation will require the nurse to obtain a telephone order?

Accepted Answer

A)  As the nurse and primary care provider leave a patient's room,the primary care provider gives the nurse an order.
B)  At 0100,a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood.
C)  At 0800,the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order.
D)  A nurse reads an order correctly as written by the primary care provider in the patient's medical record.

Question 7

A nurse is a member of an interdisciplinary team that uses critical pathways.According to the critical pathway,on day 2 of the hospital stay,the patient should be sitting in the chair.It is day 3,and the patient cannot sit in the chair.What should the nurse do?

Accepted Answer

A)  Focus charting,using the DAR format.
B)  Add this observation to the problem list.
C)  Document the variance in the patient's record.
D)  Report a positive variance in the next interdisciplinary team meeting.

Question 8

A nurse preceptor is supervising a student nurse.Which behaviour by the student nurse will require the nurse preceptor to intervene?

Accepted Answer

A)  The student nurse reviews the patient's medical record.
B)  The student nurse reads the patient's plan of care.
C)  The student nurse shares patient information with a friend.
D)  The student nurse documents medication administered to the patient.

Question 9

A nurse is giving a hand-off report to the nurse on the next shift.Which information is critical for the nurse to report?

Accepted Answer

A)  The patient had a good day with no complaints.
B)  The family is demanding and argumentative.
C)  The patient has a new pain medication,hydrocodone bitartrate and acetaminophen (Lortab) .
D)  The family is poor and had to go on welfare.

Question 10

The final "R" when using the I-SBAR-R communication technique represents which of the following?

Accepted Answer

A)  Recovery.
B)  Repeat back.
C)  Reorganization.
D)  Reintegration.

Question 11

A nurse is charting on a patient's record.Which action is most accurate legally?

Accepted Answer

A)  Charting legibly.
B)  Stating that the patient is belligerent.
C)  Using correction fluid to correct error.
D)  Writing entry for another nurse.

Question 12

A new nurse asks the preceptor why a change-of-shift report is important,inasmuch as care is documented in the chart.What is the preceptor's best response?

Accepted Answer

A)  "A change-of-shift report provides an opportunity to share essential information to ensure patient safety and continuity of care."
B)  "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs."
C)  "A change-of-shift report provides an opportunity for the oncoming nurse to ask questions and determine research priorities."
D)  "A change-of-shift report provides important information to caregivers and develops relationships within the health care team."

Question 13

A nurse wants to reduce data entry errors on the computer system.Which behaviour should the nurse implement?

Accepted Answer

A)  Use the same password all the time.
B)  Share password with only one other staff member.
C)  Print out and review computer nursing notes at home.
D)  Chart on the computer immediately after care is provided.

Question 14

A nurse is discussing the advantages of standardized documentation forms in the nursing information system.Which advantage should the nurse describe?

Accepted Answer

A)  Varied clinical databases.
B)  Reduced errors of omission.
C)  Increased hospital costs.
D)  More time to read charts.

Question 15

A nurse prepared an audiotaped exchange with another nurse of information about a patient.Which action did the nurse complete?

Accepted Answer

A)  A report.
B)  A record.
C)  A consultation.
D)  A referral.

Question 16

A nurse wants to integrate all pertinent patient information into one record,regardless of the number of times a patient enters the health care system.Which term should the nurse use to describe this system?

Accepted Answer

A)  Electronic medical record.
B)  Electronic health record.
C)  Electronic charting record.
D)  Electronic problem record.

Question 17

A preceptor is supervising a new nurse on documentation.Which situation will cause the preceptor to intervene?

Accepted Answer

A)  The new nurse uses a black ink pen to chart.
B)  The new nurse charts consecutively on every other line.
C)  The new nurse ends each entry with signature and title.
D)  The new nurse keeps the password secure.

Question 18

The action that a nurse would take when documenting on the patient's record and notes that he or she has made an error is which of the following?

Accepted Answer

A)  Drawing a line through the error and initialing and dating it.
B)  Erasing the error and writing over the material in the same spot.
C)  Using a dark-coloured marker to cover the error and continuing immediately after that point.
D)  Footnoting the error at the bottom of the page,including initials and the date.

Question 19

A slight hematoma has developed on the patient's left forearm.The nurse labels the problem as an infiltrated intravenous (IV)line.The nurse elevates the forearm.The patient states,"My arm feels better." When using the DAR notes of focus charting,the nurse would document the "R" as which of the following?

Accepted Answer

A)  "My arm feels better."
B)  "Slight hematoma on left forearm."
C)  "Infiltrated IV line."
D)  "Elevation of left forearm."

Question 20

A nurse obtained a telephone order (TO)from a primary care provider for a patient in pain.Which chart entry should the nurse document?

Accepted Answer

A)  "12/16/20,0915: Tylenol 3,2 tablets,every 6 hours for incisional pain.VO Dr.Day/J.Winds,RN,read back."
B)  "12/16/20,0915: Tylenol 3,2 tablets,every 6 hours for incisional pain.TO J.Winds,RN,read back."
C)  "12/16/20,0915: Tylenol 3,2 tablets,every 6 hours for incisional pain.TO Dr.Day/J.Winds,RN,read back."
D)  "12/16/20,0915: Tylenol 3,2 tablets,every 6 hours for incisional pain.TO J.Winds,RN."

Exam 15: Documenting and Reporting