NSG3130 EXAM 1 Latest Question and Answer
(2026/2027) | Detailed Rationales | A+ Verified
• What is necessary for hospitals to be reimbursed by Medicare or Medicaid? -✓✓
Accurate documentation according to diagnostic-related groups (DRGs).
• What reflects high-quality nursing documentation? -✓✓ High-quality nursing
documentation reflects the nursing process.
• What is the role of the medical record? -✓✓ It serves as a major communication
tool and is a legal document.
• Why are paper records being replaced by electronic health records (EHRs)? -✓✓
Paper records are fragile and susceptible to damage.
• What should a nurse do when charting in a paper medical record? -✓✓ Use
black ink unless the facility allows a different color.
• Which document provides a longitudinal record of health? -✓✓ Electronic
health record (EHR).
• What is a true statement about electronic health records? -✓✓ They improve
the overall patient's health status.
• How can a nurse protect personal health information in EHRs? -✓✓ The nurse
should never share their password with anyone, even a trusted colleague.
,• What should nursing documentation include? -✓✓ Facts and subjective data
from the patient.
• What is the nursing process that guides documentation? -✓✓ Assessment,
diagnosis, planning, implementation, and evaluation.
• What do the documentation methods PIE, APIE, SOAP, and SOAPIE have in
common? -✓✓ They are examples of problem-oriented charting.
• What type of charting records only abnormal or significant data? -✓✓ Charting
by exception (CBE).
• What document should a nurse compare provider orders with before
administering medications? -✓✓ Medication administration record (MAR).
• What is the best source for a nurse to obtain a patient's history and medications
taken at home? -✓✓ Admission summary.
• What is a key fact about paper nursing notes? -✓✓ A medical record is the most
reliable source of information in a legal action.
• What identifies the person charting in electronic documentation? -✓✓ Log-on
access to the electronic record.
• What action should a nurse take to correct an error in paper charting? -✓✓
Draw a single line through the error and write 'error' above or after the entry,
along with the nurse's initials.
, • What action must be taken when a verbal or phone order is necessary in an
emergency? -✓✓ The order must be taken by an RN or LPN, repeated verbatim to
confirm accuracy, and documented as a written order.
• What is the importance of hand-off reporting in nursing? -✓✓ Hand-off
reporting provides accurate, timely information to ensure patient safety and can
lead to collaborative problem solving.
• What should a nurse do after a patient falls while attempting to climb out of
bed? -✓✓ Complete an incident report as a risk management document.
• What components of the patient's medical record should the nurse document? -
✓✓ Nursing assessment, the care plan, and interventions.
• Which abbreviations are considered unacceptable by The Joint Commission? -
✓✓ QD, Qod, and IU.
• What are the benefits of using standardized language in nursing
documentation? -✓✓ It provides consistency, facilitates comparison of nursing
practice, promotes evidence-based quality care, and represents nursing practice
worldwide.
• What components are documented in the DAR charting format? -✓✓ Patient
problems, actions initiated, and response to interventions.
(2026/2027) | Detailed Rationales | A+ Verified
• What is necessary for hospitals to be reimbursed by Medicare or Medicaid? -✓✓
Accurate documentation according to diagnostic-related groups (DRGs).
• What reflects high-quality nursing documentation? -✓✓ High-quality nursing
documentation reflects the nursing process.
• What is the role of the medical record? -✓✓ It serves as a major communication
tool and is a legal document.
• Why are paper records being replaced by electronic health records (EHRs)? -✓✓
Paper records are fragile and susceptible to damage.
• What should a nurse do when charting in a paper medical record? -✓✓ Use
black ink unless the facility allows a different color.
• Which document provides a longitudinal record of health? -✓✓ Electronic
health record (EHR).
• What is a true statement about electronic health records? -✓✓ They improve
the overall patient's health status.
• How can a nurse protect personal health information in EHRs? -✓✓ The nurse
should never share their password with anyone, even a trusted colleague.
,• What should nursing documentation include? -✓✓ Facts and subjective data
from the patient.
• What is the nursing process that guides documentation? -✓✓ Assessment,
diagnosis, planning, implementation, and evaluation.
• What do the documentation methods PIE, APIE, SOAP, and SOAPIE have in
common? -✓✓ They are examples of problem-oriented charting.
• What type of charting records only abnormal or significant data? -✓✓ Charting
by exception (CBE).
• What document should a nurse compare provider orders with before
administering medications? -✓✓ Medication administration record (MAR).
• What is the best source for a nurse to obtain a patient's history and medications
taken at home? -✓✓ Admission summary.
• What is a key fact about paper nursing notes? -✓✓ A medical record is the most
reliable source of information in a legal action.
• What identifies the person charting in electronic documentation? -✓✓ Log-on
access to the electronic record.
• What action should a nurse take to correct an error in paper charting? -✓✓
Draw a single line through the error and write 'error' above or after the entry,
along with the nurse's initials.
, • What action must be taken when a verbal or phone order is necessary in an
emergency? -✓✓ The order must be taken by an RN or LPN, repeated verbatim to
confirm accuracy, and documented as a written order.
• What is the importance of hand-off reporting in nursing? -✓✓ Hand-off
reporting provides accurate, timely information to ensure patient safety and can
lead to collaborative problem solving.
• What should a nurse do after a patient falls while attempting to climb out of
bed? -✓✓ Complete an incident report as a risk management document.
• What components of the patient's medical record should the nurse document? -
✓✓ Nursing assessment, the care plan, and interventions.
• Which abbreviations are considered unacceptable by The Joint Commission? -
✓✓ QD, Qod, and IU.
• What are the benefits of using standardized language in nursing
documentation? -✓✓ It provides consistency, facilitates comparison of nursing
practice, promotes evidence-based quality care, and represents nursing practice
worldwide.
• What components are documented in the DAR charting format? -✓✓ Patient
problems, actions initiated, and response to interventions.
