NUR 112 - EXAM 1 UPDATED ACTUAL
Questions and CORRECT Answers
• Who should document? . CORRECT 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? . CORRECT 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? . CORRECT ANSWER: computer and software systems
(may include pager system any type of tech)
• Should you skip lines if you're charting? . CORRECT ANSWER: No!
• Approved abreviations . CORRECT 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 . CORRECT ANSWER: Health Insurance Portability and
Accountability Act
• Potential Breaches in Patient Confidentiality . CORRECT ANSWER:
Displaying information on a public screen
-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? . CORRECT 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: . CORRECT 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? . CORRECT ANSWER: patient's
cannot revise info
• Documentation . CORRECT ANSWER: written or electronic legal record kept
by nurses for assessing and planning
• What is the nursing process? . CORRECT ANSWER: Assessment
Diagnosis
Planning
Implementation
Evaluation
• content must be factual - meaning what can you see? . CORRECT ANSWER:
examples: Shortness of breath, cardiac arrest, patient is in use of oxygen with 2
Liters, etc.
, • Factual charting example vs. not . CORRECT ANSWER: Factual: patient is
lying in bed at 15 degrees with eyes closed
not: patient is sleeping
factual: BP is 130/70 taken at 1430not: patient BP is within normal limits (Always
use numbers if available)
• Who is responsible for their chart? . CORRECT ANSWER: The person who
completed the surgical procedure (the process of removing or handling sterile
materials)
• Everything charting related will be in military time. . CORRECT ANSWER:
True
• Timing . CORRECT ANSWER: always write down date and time you
completed an activity so you can refer back when charting on lehgal documents
• policy for receiving verbal orders in an emergency: . CORRECT ANSWER: -
record
-read
-date
-record
ALWAYS READ ORDER BACK WHEN ON PHONE WITH M.D. OR CRNP
• Policy for M.D. or CRNP review of V.O. (verbal order) . CORRECT ANSWER:
- review order for accuracy
- sign order with name, title, and pager number
- date and note time orders signed
Questions and CORRECT Answers
• Who should document? . CORRECT 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? . CORRECT 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? . CORRECT ANSWER: computer and software systems
(may include pager system any type of tech)
• Should you skip lines if you're charting? . CORRECT ANSWER: No!
• Approved abreviations . CORRECT 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 . CORRECT ANSWER: Health Insurance Portability and
Accountability Act
• Potential Breaches in Patient Confidentiality . CORRECT ANSWER:
Displaying information on a public screen
-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? . CORRECT 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: . CORRECT 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? . CORRECT ANSWER: patient's
cannot revise info
• Documentation . CORRECT ANSWER: written or electronic legal record kept
by nurses for assessing and planning
• What is the nursing process? . CORRECT ANSWER: Assessment
Diagnosis
Planning
Implementation
Evaluation
• content must be factual - meaning what can you see? . CORRECT ANSWER:
examples: Shortness of breath, cardiac arrest, patient is in use of oxygen with 2
Liters, etc.
, • Factual charting example vs. not . CORRECT ANSWER: Factual: patient is
lying in bed at 15 degrees with eyes closed
not: patient is sleeping
factual: BP is 130/70 taken at 1430not: patient BP is within normal limits (Always
use numbers if available)
• Who is responsible for their chart? . CORRECT ANSWER: The person who
completed the surgical procedure (the process of removing or handling sterile
materials)
• Everything charting related will be in military time. . CORRECT ANSWER:
True
• Timing . CORRECT ANSWER: always write down date and time you
completed an activity so you can refer back when charting on lehgal documents
• policy for receiving verbal orders in an emergency: . CORRECT ANSWER: -
record
-read
-date
-record
ALWAYS READ ORDER BACK WHEN ON PHONE WITH M.D. OR CRNP
• Policy for M.D. or CRNP review of V.O. (verbal order) . CORRECT ANSWER:
- review order for accuracy
- sign order with name, title, and pager number
- date and note time orders signed
