PN - Foundations of Nursing:
Final Review Exam Study Guide
– Practice Questions with
Verified Answers. GRADED A+.
Latest 2026/2027 Update
What is the purpose of the health record in nursing? - Answer✔✔-To provide a
clear understanding and a picture of the patient, allowing the interprofessional
team to communicate effectively.
What does SBARR stand for in nursing documentation? - Answer✔✔-SBARR
stands for Situation, Background, Assessment, Recommendation, and
Readback.
What information must be obtained when receiving a telephone order? -
Answer✔✔-The specific details of the order, including the medication, dosage,
route, and any relevant patient information.
What are the guidelines for accurate documentation in a health record? -
Answer✔✔-Documentation must be clear, accurate, concise, and accessible,
and should include approved abbreviations, be timely, specific, and complete.
,What are the legal considerations related to documentation in a health record?
- Answer✔✔-Documentation must be objective, avoid opinions or
assumptions, and should never chart under someone else's name.
What are the phases of the nursing process? - Answer✔✔-The phases include
assessment, diagnosis, planning, implementation, and evaluation.
How does Maslow's Hierarchy of needs apply to nursing practice? -
Answer✔✔-It helps nurses prioritize patient care based on their basic needs,
such as physiological, safety, love/belonging, esteem, and self-actualization.
What information should be included in a transfer report? - Answer✔✔-
Patient's current condition, treatment received, medications, and any special
considerations or instructions.
What are the nurse's responsibilities during admission, transfer, and discharge?
- Answer✔✔-To ensure accurate documentation, communicate effectively with
the patient and team, and provide appropriate care throughout the process.
What are common patient reactions to hospitalization? - Answer✔✔-Anxiety,
fear, depression, and feelings of loss of control.
What nursing interventions can address common patient reactions to
hospitalization? - Answer✔✔-Providing emotional support, clear
communication, and involving patients in their care decisions.
,What are the charting rules for nursing documentation? - Answer✔✔-All
sheets must have correct patient identification, and documentation should be
timely, specific, and accurate.
What should be avoided when charting patient observations? - Answer✔✔-
General phrases, opinions, assumptions, and judgmental terms.
What is the protocol for late charting entries? - Answer✔✔-Identify the entry
as a 'late entry,' specify the time of the event, and ensure all new entries are
signed and dated.
How should errors in documentation be corrected? - Answer✔✔-Draw a single
line through the entry, write 'error' with your initials, and record the date and
time of the correction.
What is the significance of documenting interventions in nursing? -
Answer✔✔-It is essential for meeting patient needs, ensuring continuity of
care, and necessary for reimbursement.
What should be included when documenting patient responses to treatments?
- Answer✔✔-Specific observations of the patient's reactions to treatments or
medications.
What is the importance of charting after care is given? - Answer✔✔-To ensure
accurate and timely documentation of the care provided.
What should be done if an order is questioned? - Answer✔✔-Record that
clarification was sought regarding the order.
, What is the recommended timeframe for administering and charting
medications? - Answer✔✔-Generally, you have an hour before and an hour
after a medication is due.
What should be included in documentation when a patient leaves the unit? -
Answer✔✔-The time and method of transportation upon departure and
return.
Why is it important to avoid using White Out or similar products in
documentation? - Answer✔✔-To keep the original entry readable and maintain
the integrity of the health record.
What is the role of documentation in the implementation phase of the nursing
process? - Answer✔✔-It serves as a record of the actions taken to meet patient
needs and is crucial for continuity of care.
What does the acronym SBARR stand for in reporting? - Answer✔✔-Situation,
Background, Assessment, Recommendation, and Read back.
What is the purpose of reporting in healthcare? - Answer✔✔-To provide
continuity of care and enhance communication among all team members.
What should nurses ensure during reporting to uphold patient privacy? -
Answer✔✔-Conduct reporting in a confidential manner to ensure HIPAA is
upheld.
Final Review Exam Study Guide
– Practice Questions with
Verified Answers. GRADED A+.
Latest 2026/2027 Update
What is the purpose of the health record in nursing? - Answer✔✔-To provide a
clear understanding and a picture of the patient, allowing the interprofessional
team to communicate effectively.
What does SBARR stand for in nursing documentation? - Answer✔✔-SBARR
stands for Situation, Background, Assessment, Recommendation, and
Readback.
What information must be obtained when receiving a telephone order? -
Answer✔✔-The specific details of the order, including the medication, dosage,
route, and any relevant patient information.
What are the guidelines for accurate documentation in a health record? -
Answer✔✔-Documentation must be clear, accurate, concise, and accessible,
and should include approved abbreviations, be timely, specific, and complete.
,What are the legal considerations related to documentation in a health record?
- Answer✔✔-Documentation must be objective, avoid opinions or
assumptions, and should never chart under someone else's name.
What are the phases of the nursing process? - Answer✔✔-The phases include
assessment, diagnosis, planning, implementation, and evaluation.
How does Maslow's Hierarchy of needs apply to nursing practice? -
Answer✔✔-It helps nurses prioritize patient care based on their basic needs,
such as physiological, safety, love/belonging, esteem, and self-actualization.
What information should be included in a transfer report? - Answer✔✔-
Patient's current condition, treatment received, medications, and any special
considerations or instructions.
What are the nurse's responsibilities during admission, transfer, and discharge?
- Answer✔✔-To ensure accurate documentation, communicate effectively with
the patient and team, and provide appropriate care throughout the process.
What are common patient reactions to hospitalization? - Answer✔✔-Anxiety,
fear, depression, and feelings of loss of control.
What nursing interventions can address common patient reactions to
hospitalization? - Answer✔✔-Providing emotional support, clear
communication, and involving patients in their care decisions.
,What are the charting rules for nursing documentation? - Answer✔✔-All
sheets must have correct patient identification, and documentation should be
timely, specific, and accurate.
What should be avoided when charting patient observations? - Answer✔✔-
General phrases, opinions, assumptions, and judgmental terms.
What is the protocol for late charting entries? - Answer✔✔-Identify the entry
as a 'late entry,' specify the time of the event, and ensure all new entries are
signed and dated.
How should errors in documentation be corrected? - Answer✔✔-Draw a single
line through the entry, write 'error' with your initials, and record the date and
time of the correction.
What is the significance of documenting interventions in nursing? -
Answer✔✔-It is essential for meeting patient needs, ensuring continuity of
care, and necessary for reimbursement.
What should be included when documenting patient responses to treatments?
- Answer✔✔-Specific observations of the patient's reactions to treatments or
medications.
What is the importance of charting after care is given? - Answer✔✔-To ensure
accurate and timely documentation of the care provided.
What should be done if an order is questioned? - Answer✔✔-Record that
clarification was sought regarding the order.
, What is the recommended timeframe for administering and charting
medications? - Answer✔✔-Generally, you have an hour before and an hour
after a medication is due.
What should be included in documentation when a patient leaves the unit? -
Answer✔✔-The time and method of transportation upon departure and
return.
Why is it important to avoid using White Out or similar products in
documentation? - Answer✔✔-To keep the original entry readable and maintain
the integrity of the health record.
What is the role of documentation in the implementation phase of the nursing
process? - Answer✔✔-It serves as a record of the actions taken to meet patient
needs and is crucial for continuity of care.
What does the acronym SBARR stand for in reporting? - Answer✔✔-Situation,
Background, Assessment, Recommendation, and Read back.
What is the purpose of reporting in healthcare? - Answer✔✔-To provide
continuity of care and enhance communication among all team members.
What should nurses ensure during reporting to uphold patient privacy? -
Answer✔✔-Conduct reporting in a confidential manner to ensure HIPAA is
upheld.
