NUR 112 - EXAM 1 (2026) Exam Questions & Answers | Latest Already
Graded A+ UPDATE 2025|2026!! STUDY GUIDE EXAM
Elements of Documentation (Guidelines) - (ANSWER)- accessible
- accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing- specific manner.
Who should document? - (ANSWER)Whoever is responsible for the nurses care should chart but others
can chart in as well. Everyone should document!!!
Why should you document without error? - (ANSWER)Poor documentation can be presumed as medical
negligence. "CYA".
Make sure you're documenting without error/ i.e. Don't document the wrong BP. Can possibly affect
medication dosage.
Errors make nurses look less credible. Which can affect credibility.
What is informatics? - (ANSWER)computer and software systems (may include pager system any type of
tech)
Should you skip lines if you're charting? - (ANSWER)No!
,NUR 112 - EXAM 1 (2026) Exam Questions & Answers | Latest Already
Graded A+ UPDATE 2025|2026!! STUDY GUIDE EXAM
Approved abreviations - (ANSWER)A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
s- without
ss- one-half
t.i.d.- three times a day
What is HIPAA - (ANSWER)Health Insurance Portability and Accountability Act
Potential Breaches in Patient Confidentiality - (ANSWER)Displaying information on a public screen
, NUR 112 - EXAM 1 (2026) Exam Questions & Answers | Latest Already
Graded A+ UPDATE 2025|2026!! STUDY GUIDE EXAM
-Sending confidential e-mail messages via public networks
-Sharing printers among units with differing functions
-Discarding copies of patient information in trash cans
-Holding conversations that can be overheard
-Faxing confidential information to unauthorized persons
-Sending confidential messages overheard on pagers
Hypothetically, if a patient had yellow skin, was not wearing pants, was smiling, and its stomach is
sticking out, and the patient also states, "I'm rumbly in my tummly." How would you chart this? -
(ANSWER)Patient has generalized jaundice. Ambulating in room. Patient is not wearing pants. Protruding
abdomen. The patient is smiling. No signs of distress. Patient states I'm rumbly in my tummy. Patient "I'm
hungry".
Patient's have the right to: - (ANSWER)-See and copy their health record
-Update their health record
-Get a list of disclosures
-Request a restriction on certain uses or disclosures
-Choose how to receive health information
what can patient's NOT do to their paperwork? - (ANSWER)patient's cannot revise info
Documentation - (ANSWER)written or electronic legal record kept by nurses for assessing and planning
What is the nursing process? - (ANSWER)Assessment
Diagnosis
Planning
Implementation
Evaluation
Graded A+ UPDATE 2025|2026!! STUDY GUIDE EXAM
Elements of Documentation (Guidelines) - (ANSWER)- accessible
- accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing- specific manner.
Who should document? - (ANSWER)Whoever is responsible for the nurses care should chart but others
can chart in as well. Everyone should document!!!
Why should you document without error? - (ANSWER)Poor documentation can be presumed as medical
negligence. "CYA".
Make sure you're documenting without error/ i.e. Don't document the wrong BP. Can possibly affect
medication dosage.
Errors make nurses look less credible. Which can affect credibility.
What is informatics? - (ANSWER)computer and software systems (may include pager system any type of
tech)
Should you skip lines if you're charting? - (ANSWER)No!
,NUR 112 - EXAM 1 (2026) Exam Questions & Answers | Latest Already
Graded A+ UPDATE 2025|2026!! STUDY GUIDE EXAM
Approved abreviations - (ANSWER)A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
s- without
ss- one-half
t.i.d.- three times a day
What is HIPAA - (ANSWER)Health Insurance Portability and Accountability Act
Potential Breaches in Patient Confidentiality - (ANSWER)Displaying information on a public screen
, NUR 112 - EXAM 1 (2026) Exam Questions & Answers | Latest Already
Graded A+ UPDATE 2025|2026!! STUDY GUIDE EXAM
-Sending confidential e-mail messages via public networks
-Sharing printers among units with differing functions
-Discarding copies of patient information in trash cans
-Holding conversations that can be overheard
-Faxing confidential information to unauthorized persons
-Sending confidential messages overheard on pagers
Hypothetically, if a patient had yellow skin, was not wearing pants, was smiling, and its stomach is
sticking out, and the patient also states, "I'm rumbly in my tummly." How would you chart this? -
(ANSWER)Patient has generalized jaundice. Ambulating in room. Patient is not wearing pants. Protruding
abdomen. The patient is smiling. No signs of distress. Patient states I'm rumbly in my tummy. Patient "I'm
hungry".
Patient's have the right to: - (ANSWER)-See and copy their health record
-Update their health record
-Get a list of disclosures
-Request a restriction on certain uses or disclosures
-Choose how to receive health information
what can patient's NOT do to their paperwork? - (ANSWER)patient's cannot revise info
Documentation - (ANSWER)written or electronic legal record kept by nurses for assessing and planning
What is the nursing process? - (ANSWER)Assessment
Diagnosis
Planning
Implementation
Evaluation
