NFDN 1002 MIDTERM UNITS 1-4 EXAM QUESTIONS AND
ANSWERS
Intrapersonal Communication - CORRECT ANSWER✅✅communication with oneself
Interpersonal Communication - CORRECT ANSWER✅✅between two or more people
Transpersonal Communication - CORRECT ANSWER✅✅interaction that occurs within a person's
spiritual domain
SOAP Charting - CORRECT ANSWER✅✅S= Subjective data (how the patient feels)
O= Objective data (results of physical exam, vital signs, etc)
A= Assessment (what is the patient's status)
P= Plan (does the plan stay the same or is change needed?)
SOAPIE Charting - CORRECT ANSWER✅✅I= Intervention (what did the nurse do?)
E= Evaluation (what is the patient outcome following the intervention?)
PIE Charting - CORRECT ANSWER✅✅P= Patient problems (teaching needs and discharge planning
needs, identified during initial assessment of the patient)
I= Interventions carried out for each specific nursing diagnosis
E= Evaluate the outcomes of the interventions
DAR - CORRECT ANSWER✅✅Data: information that supports the focus
Action: the nursing intervention
Response: how the patient responds to the intervention and the outcome
Focus Charting - CORRECT ANSWER✅✅Eliminates the word "problem" and uses the term "focus"
Includes patient's condition, nursing diagnosis, s&s, or significant event or change in condition
,Organized using DAR
Source-Oriented Charting - CORRECT ANSWER✅✅Most common
Information is organized & presented according to its source
There are separate sections for the doctor's notes, the nurse's notes, the respiratory therapist notes, etc
Read through all the sections & piece together the data
Charting by Exception - CORRECT ANSWER✅✅Chart only when there is a significant change or finding
different from the norm
Otherwise use standardized flow sheets, nursing database, SOAP progress notes and care plans
CBE use narrative format
Alerts staff to something unusual that has occurred with the patient
Presumes that unless documented otherwise, all standards have been met with a normal response
A.C. - CORRECT ANSWER✅✅before meals
P.C. - CORRECT ANSWER✅✅after meals
NKA - CORRECT ANSWER✅✅No known allergies
NPO - CORRECT ANSWER✅✅Nothing per mouth
HOB - CORRECT ANSWER✅✅Head of bed
W/C - CORRECT ANSWER✅✅wheelchair
SOB - CORRECT ANSWER✅✅Shortness of breath
, PRN - CORRECT ANSWER✅✅As needed
TPR - CORRECT ANSWER✅✅temperature, pulse, respiration
Written Orders - CORRECT ANSWER✅✅Physically written by the physician on the chart
Verbal Orders - CORRECT ANSWER✅✅Given to the nurse while in their presence
Not written on the chart
Telephone Orders - CORRECT ANSWER✅✅Given to the nurse via telephone
Electronic Orders - CORRECT ANSWER✅✅Written through the electronic health system of the facility
Processing a Verbal Order - CORRECT ANSWER✅✅Verify
Clarify
Transcribe
Factors that increase Fall Risk - CORRECT ANSWER✅✅Age
Fear of falling
Footwear and foot care
Medications
Chronic and acute illnesses
Fall Risk Assessments - CORRECT ANSWER✅✅When admitted
Once a year
When there is a change in client condition (e.g. change in mobility status)
Code Yellow - CORRECT ANSWER✅✅Missing client
ANSWERS
Intrapersonal Communication - CORRECT ANSWER✅✅communication with oneself
Interpersonal Communication - CORRECT ANSWER✅✅between two or more people
Transpersonal Communication - CORRECT ANSWER✅✅interaction that occurs within a person's
spiritual domain
SOAP Charting - CORRECT ANSWER✅✅S= Subjective data (how the patient feels)
O= Objective data (results of physical exam, vital signs, etc)
A= Assessment (what is the patient's status)
P= Plan (does the plan stay the same or is change needed?)
SOAPIE Charting - CORRECT ANSWER✅✅I= Intervention (what did the nurse do?)
E= Evaluation (what is the patient outcome following the intervention?)
PIE Charting - CORRECT ANSWER✅✅P= Patient problems (teaching needs and discharge planning
needs, identified during initial assessment of the patient)
I= Interventions carried out for each specific nursing diagnosis
E= Evaluate the outcomes of the interventions
DAR - CORRECT ANSWER✅✅Data: information that supports the focus
Action: the nursing intervention
Response: how the patient responds to the intervention and the outcome
Focus Charting - CORRECT ANSWER✅✅Eliminates the word "problem" and uses the term "focus"
Includes patient's condition, nursing diagnosis, s&s, or significant event or change in condition
,Organized using DAR
Source-Oriented Charting - CORRECT ANSWER✅✅Most common
Information is organized & presented according to its source
There are separate sections for the doctor's notes, the nurse's notes, the respiratory therapist notes, etc
Read through all the sections & piece together the data
Charting by Exception - CORRECT ANSWER✅✅Chart only when there is a significant change or finding
different from the norm
Otherwise use standardized flow sheets, nursing database, SOAP progress notes and care plans
CBE use narrative format
Alerts staff to something unusual that has occurred with the patient
Presumes that unless documented otherwise, all standards have been met with a normal response
A.C. - CORRECT ANSWER✅✅before meals
P.C. - CORRECT ANSWER✅✅after meals
NKA - CORRECT ANSWER✅✅No known allergies
NPO - CORRECT ANSWER✅✅Nothing per mouth
HOB - CORRECT ANSWER✅✅Head of bed
W/C - CORRECT ANSWER✅✅wheelchair
SOB - CORRECT ANSWER✅✅Shortness of breath
, PRN - CORRECT ANSWER✅✅As needed
TPR - CORRECT ANSWER✅✅temperature, pulse, respiration
Written Orders - CORRECT ANSWER✅✅Physically written by the physician on the chart
Verbal Orders - CORRECT ANSWER✅✅Given to the nurse while in their presence
Not written on the chart
Telephone Orders - CORRECT ANSWER✅✅Given to the nurse via telephone
Electronic Orders - CORRECT ANSWER✅✅Written through the electronic health system of the facility
Processing a Verbal Order - CORRECT ANSWER✅✅Verify
Clarify
Transcribe
Factors that increase Fall Risk - CORRECT ANSWER✅✅Age
Fear of falling
Footwear and foot care
Medications
Chronic and acute illnesses
Fall Risk Assessments - CORRECT ANSWER✅✅When admitted
Once a year
When there is a change in client condition (e.g. change in mobility status)
Code Yellow - CORRECT ANSWER✅✅Missing client
