NRS-2024 FUNDAMENTAL Exam 1 Review: Questions With Complete Solutions

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? - ANSWER-Client complaining of abdominal pain rated at 8/10. A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym? - ANSWER-Client complaints of pain Which note includes all elements of a SOAP note? - ANSWER-Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? - ANSWER-Subjective data should be included when documenting. What is the nurse's best defense if a patient alleges nursing negligence? - ANSWER-patients record A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality? - ANSWER-Writing the client's name on the student care plan What is confidential information? - ANSWER-All information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud. This includes patient names and all identifiers such as address, telephone and fax number, Social Security number, and any other personal information. It also includes the reason the patient is sick or in the hospital, office, or clinic, the assessments and treatments the patient receives, and information about past health conditions