Question 1

The patient has fallen when trying to climb out of bed. The nurse:

Accepted Answer

A)  needs to complete an incident report as a risk management document. 
B)  completes an incident report since it is a permanent part of the medical record. 
C)  must document that an incident report was completed in the medical record. 
D)  should say nothing about the incident in the medical record. 
A)  needs to complete an incident report as a risk management document. 
B)  completes an incident report since it is a permanent part of the medical record. 
C)  must document that an incident report was completed in the medical record. 
D)  should say nothing about the incident in the medical record. A

Question 2

Paper records are being replaced by other forms of record keeping because:

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. A

Question 3

PIE, APIE, SOAP, and SOAPIE are:

Accepted Answer

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

Question 4

The Health Insurance Portability and Accountability Act (HIPAA) mandates that health information can be shared: (Select all that apply.)

Accepted Answer

A)  In order 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)  In order 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

Question 5

The process of making a change-of-shift report (handoff):

Accepted Answer

A)  is an uncommon occurrence of little importance. 
B)  occurs only at change of shift and only to oncoming nurses. 
C)  can lead to patient death if done incorrectly. 
D)  does not allow for collaboration or problem solving. 
A)  is an uncommon occurrence of little importance. 
B)  occurs only at change of shift and only to oncoming nurses. 
C)  can lead to patient death if done incorrectly. 
D)  does not allow for collaboration or problem solving.

Question 6

Which of the following is 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 7

Nurses must be aware of the danger of using abbreviations that may be misunderstood and compromise patient safety. The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. Of the following, which are acceptable? (Select all that apply.)

Accepted Answer

A)  Daily 
B)  QD 
C)  qod 
D) 0.X mg 
E)  X mg 
A)  Daily 
B)  QD 
C)  qod 
D) 0.X mg 
E)  X mg

Question 8

The nurse is admitting a patient who has had several previous admissions. In order to obtain a knowledge base about the patient's medical history, the nurse may use the:

Accepted Answer

A)  electronic medical record (EMR). 
B)  the computerized provider order entry (CPO
E) . 
C)  electronic health record (EHR). 
D)  American Recovery and Reinvestment Act. 
A)  electronic medical record (EMR). 
B)  the computerized provider order entry (CPO
E) . 
C)  electronic health record (EHR). 
D)  American Recovery and Reinvestment Act.

Question 9

Standardized nursing terminologies such as the North American Nursing Diagnosis Association-International (NANDA-I) nursing diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) may be used in the documentation process. Use of standardized language: (Select all that apply.)

Accepted Answer

A)  provides consistency. 
B)  improves communication among nurses while excluding non-nurses. 
C)  increases the visibility of nursing interventions. 
D)  enhances data collection. 
E)  supports adherence to care standards. 
A)  provides consistency. 
B)  improves communication among nurses while excluding non-nurses. 
C)  increases the visibility of nursing interventions. 
D)  enhances data collection. 
E)  supports adherence to care standards.

Question 10

The nurse is charting in the paper medical record. She should:

Accepted Answer

A)  print his/her name since signatures are often not readable. 
B)  not document her credentials since everyone knows that she is a nurse. 
C)  skip a line, leaving a blank space, between entries so that it looks neater. 
D)  use black ink unless the facility allows a different color. 
A)  print his/her name since signatures are often not readable. 
B)  not document her credentials since everyone knows that she is a nurse. 
C)  skip a line, leaving a blank space, between entries so that it looks neater. 
D)  use black ink unless the facility allows a different color.

Question 11

How should the nurse correct an error in 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, and then write "error" above or after the entry 
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, and then write "error" above or after the entry 
D)  leave the entry as is and tell the charge nurse.

Question 12

Nursing documentation is guided by:

Accepted Answer

A)  the Nursing process 
B)  the North American Nursing Diagnosis Association (NAND
A)  diagnoses. 
C)  Nursing Interventions Classification. 
D)  Nursing Outcomes Classification 
A)  the Nursing process 
B)  the North American Nursing Diagnosis Association (NAND
A)  diagnoses. 
C)  Nursing Interventions Classification. 
D)  Nursing Outcomes Classification

Question 13

Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:

Accepted Answer

A)  documents facts. 
B)  documents how he/she feels about the care being provided. 
C)  documents in a "block" fashion once per shift. 
D)  double documents as often as possible in order to not miss anything. 
A)  documents facts. 
B)  documents how he/she feels about the care being provided. 
C)  documents in a "block" fashion once per shift. 
D)  double documents as often as possible in order to not miss anything.

Question 14

The nurse is preparing to administer medications to the patient. Prior to doing so, she/he compares the provider orders with the:

Accepted Answer

A)  flow sheet 
B)  Kardex 
C)  MAR 
D)  admission summary 
A)  flow sheet 
B)  Kardex 
C)  MAR 
D)  admission summary

Question 15

The nurse is charting using electronic documentation. With 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 16

A type of charting that records only abnormal or significant data is:

Accepted Answer

A)  PIE. 
B)  SOAP. 
C)  narrative. 
D)  charting by exception. 
A)  PIE. 
B)  SOAP. 
C)  narrative. 
D)  charting by exception.

Question 17

The nurse is caring for patients on unit that uses electronic health records (EHRs). In order to protect personal health information, the nurse should:

Accepted Answer

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

Question 18

The nurse is charting using the DAR charting system. This form of charting requires documentation about: (Select all that apply.)

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 19

The medical record:

Accepted Answer

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

Question 20

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

Accepted Answer

A)  admission summary. 
B)  discharge summary. 
C)  flow sheet. 
D)  Kardex. 
A)  admission summary. 
B)  discharge summary. 
C)  flow sheet. 
D)  Kardex.

Exam 10: Documentation, Electronic Health Records, and Reporting

The patient has fallen when trying to climb out of bed. The nurse:

Paper records are being replaced by other forms of record keeping because:

PIE, APIE, SOAP, and SOAPIE are:

The Health Insurance Portability and Accountability Act (HIPAA) mandates that health information can be shared: (Select all that apply.)

The process of making a change-of-shift report (handoff):

Which of the following is true regarding nursing documentation?

The nurse is admitting a patient who has had several previous admissions. In order to obtain a knowledge base about the patient's medical history, the nurse may use the:

The nurse is charting in the paper medical record. She should:

How should the nurse correct an error in charting?

Nursing documentation is guided by:

Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:

The nurse is preparing to administer medications to the patient. Prior to doing so, she/he compares the provider orders with the:

The nurse is charting using electronic documentation. With electronic documentation:

A type of charting that records only abnormal or significant data is:

The nurse is caring for patients on unit that uses electronic health records (EHRs). In order to protect personal health information, the nurse should:

The nurse is charting using the DAR charting system. This form of charting requires documentation about: (Select all that apply.)

The medical record:

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

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 to Older Adult

Vital Signs

Health History and Physical Assessment

Ethnicity and Cultural Assessment

Spiritual Health

Public Health, Community Base, 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

Filters