NRS 101 EXAM 1 QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026

NRS 101 EXAM 1 QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026 Nurses are responsible for protecting records from - Answers all unauthorized readers Confidential permanent legal document - Answers Records or chart Oral, written, or audiotaped exchange of information - Answers Reports Team members communicating in a group - Answers Conferences A professional caregiver giving formal advice to another caregiver - Answers Consultations Arrangement for services by another care provider - Answers Referrals Purposes of Records - Answers Communication Legal documentation Reimbursement Education Research Auditing/monitoring What is the correct method for correcting an error in a paper record - Answers Draw a single line through the error, write the word "error" above it, sign your initials, and date it. Guidelines for Quality Documentation and Reporting - Answers Factual Accurate Complete Current Organized Key information may be lost from one episode of care to the next. - Answers Paper record A digital version of a patient's medical record Integrates all of a patient's information in one record Improves continuity of care - Answers Electronic health record (EHR) Methods of Recording - Answers Narrative and Problem-oriented medical record Methods of Recording: Progress Notes - Answers SOAP, SOAPIE, PIE, FOCUS CHARTING Subjective, objective, assessment, plan - Answers SOAP Subjective, objective, assessment, plan, intervention, evaluation - Answers SOAPIE Problem, intervention, evaluation - Answers PIE Data, action, response - Answers Focus charting (DAR) Focuses on documenting deviations - Answers Charting by exception (CBE) Incorporate a multidisciplinary approach to care - Answers Case management plan and critical pathways Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems - Answers Admission nursing history form Help team members quickly see patient trends over time and decrease time spent on writing narrative notes - Answers Flow sheets and graphic records A portable "flip-over" file or notebook with patient information - Answers Patient care summary or Kardex Preprinted, established guidelines used to care for patients who have similar health problems - Answers Standardized care plans common record keeping forms - Answers Standardized care plans Discharge summary forms Acuity records the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. - Answers Documentation Occurs with transfer of patient care Provides continuity and individualized care Reports are quick and efficient. - Answers Hand-off report Not used to change patients plan of care For performance improvements - Answers Incident or occurrence reports Percent change between 1980 and 2000 in RNs employed in selected settings. Public/Community health = Ambulatory Care = Hospitals = Nursing Homes/Ext. Care = - Answers Public/Community health = 155% Ambulatory Care = 125% Hospitals = 55% Nursing Homes/Ext. Care = 50% By 2015 nursing shortage to reach ____ and increase to ____ - Answers 20% and increase to 29% Acute Care is provided in - Answers hospital setting Community-Based Care provided in - Answers ambulatory care, surgical centers, dialysis centers, rehab, clinics, Dr. offices, home A nursing specialty like OB, critical care, etc. Requires specific knowledge and skills. - Answers Community health nursing not defined by setting or level of academic preparation but by philosophy of practice about HOW the nurse practices - Answers Community-Based nursing community branches into - Answers people, location, and social system community based care is - Answers family centered care Vital statistics and demographics describe community and its needs - Answers people Boundaries : geographic, political, problematic - Answers location Economy, education, religion, politics, recreation, legal system, health care, safety and transportation, communication - Answers social system Four components to nursing practice (no matter what the setting) - Answers Client Environment Health Nursing in the community the client is - Answers individuals, families, communities (things like assisted living that whole community is your client/ or the whole family depending on the individual) components of community based care - Answers self care, preventive health care, Care within Context of the Community, Continuity of Care, Collaborative Care focus in self-care is not on curing but - Answers empowering patients to take care of themselves The client and the family are most responsible for _______ - Answers their health Three types of Preventive Health Care - Answers Primary, Secondary, Tertiary prevent the initial injury or disease (flu shot, education) - Answers Primary Prevention maximizing recovery after injury or illness (therapies) - Answers Tertiary Prevention early identification and treatment of disease to limit disability (lots of screening, mammogram) - Answers Secondary Prevention nursing care provided while considering culture, values, resources of client, family, community - Answers Care within Context of the Community what is important for the nurse whether the nurse is working in acute care or in the community - Answers the more he/she knows about the community the better care he/she can provide. coordination involving clients, providers and payers to promote the delivery of health care - Answers Continuity of Care the focus in continuity of care is : - Answers CONTINUTIY of care in ALL settings. continuity of care is designed to _____________ as they move between and among health care settings - Answers meet needs of people collaboration among healthcare professionals - Answers Collaborative Care Nurse consistently and effectively uses interpersonal communication to - Answers establish, maintain, and terminate a therapeutic relationship Leadership abilities to carry out - Answers planning, organizing, coordinating, delegating and evaluating care Critical Thinking includes - Answers questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application and creativity documentation may only be done by who and why is it neccessary? - Answers Nurse may be the only one documenting care Necessary for reimbursement is an ongoing process - Answers Evaluation _______________ lead nurses to conclude that interventions were __________ - Answers Positive evaluations; successful Nursing care helps patients - Answers Resolve actual health problems Prevent potential problems Maintain a healthy state American Nurses Association (ANA) does what - Answers defines standards of professional nursing practice Criterion-based standards for evaluation are the __________, __________, and ____________ responses that are a patient's goals and expected outcomes - Answers physiological, emotional, and behavioral Expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state - Answers Goal End result that is measurable, desirable, and observable and translates into observable patient behaviors - Answers Expected outcome Collaborate and Evaluate Effectiveness of Interventions - Answers Collaborate with the patient and family. Use evaluative measures. Interpret and summarize findings. Document results. Revise care plan. What are the steps needed to objectively evaluate the degree of success in achieving outcomes of care - Answers 1. Examine the outcome criteria. 2. Evaluate the patient's actual response. 3. Compare the established outcome criteria with the actual response. 4. Judge the degree of agreement between the outcome criteria and the response. 5. If no or only partial agreement, what are the barriers? Discontinuing a care plan - Answers Has the goal been met? Does the patient agree? Document the discontinued plan. If goals are unmet or are only partially met, you should __________________ •You may need to - Answers continue the intervention. create a new plan of care and redefine priorities to achieve goals Modifying a care plan: - Answers Reassessment Redefining diagnoses Goals and expected outcomes any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes - Answers nursing intervention Where do you get your interventions? - Answers after R/T (related to) What is the implementation process? - Answers -reassessing the patient, -reviewing and revising the existing nursing care plan, -organizing resources and care delivery, -anticipating and preventing complications Systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate healthcare for specific clinical situations - Answers Guidelines and Protocols A preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems - Answers Standing Orders four steps that help you anticipate and prevent complications. - Answers -Identify risks to the patient. -Adapt interventions to the situation. -Evaluate the relative benefit of a treatment vs. the risk. -Initiate risk prevention measures. implementation skills - Answers Cognitive skills Interpersonal skills Psychomotor skills These three skills are needed to implement - Answers direct and indirect nursing interventions. Application of critical thinking in the nursing process - Answers Cognitive skills Developing a trusting relationship, expressing a level of caring, and communicating clearly with a patient and his or her family - Answers Interpersonal skills Integration of cognitive and motor activities - Answers Psychomotor skills Treatments performed through interactions with patients Examples: -Medication administration -Insertion of an intravenous (IV) infusion -Counseling during a time of grief - Answers direct care Treatments performed away from the patient but on behalf of the patient or group of patients Examples: -Managing the patient's environment (e.g., safety and infection control) -Documentation -Interdisciplinary collaboration - Answers indirect care a specific and measurable behavior or response that reflects a patients highest possible level of wellness and independence in function - Answers patient-centered goal an objective behavior or response expected within hours to a week - Answers short-term goal an objective behavior or response expected within days, weeks, or months - Answers long-term goal What is SMART? - Answers -Specific goal or outcome