The Nursing Process and
Documentation Questions and Answers
Already Passed
What should a nurse document when observing a new wound on a patient?
✔✔ Describe the wound’s size, location, appearance, and any signs of infection, and note when
the wound was first observed.
How does documenting a patient’s nutritional intake contribute to their care?
✔✔ It provides insights into the patient’s dietary needs, helps monitor changes in weight or
health status, and guides adjustments to the care plan.
What should be documented when a patient exhibits an allergic reaction?
✔✔ Record the symptoms, the time of onset, any interventions taken, and the patient’s response
to those interventions.
How can a nurse document the use of assistive devices for a patient?
✔✔ Note the type of device used, the patient’s level of assistance required, and any issues or
improvements observed.
1
,What is the significance of documenting patient consent for medications?
✔✔ It confirms that the patient has been informed about the medication, understands its purpose,
and agrees to its administration.
How should a nurse document the outcome of a patient’s follow-up visit?
✔✔ Include the patient’s progress, any changes in their condition, and updates to the care plan
based on the follow-up assessment.
What information should be included when documenting a patient’s emotional state?
✔✔ Describe observed behaviors, reported feelings, any contributing factors, and how the
emotional state affects the patient’s overall care.
How does documenting patient goals help in the nursing process?
✔✔ It provides clear, measurable objectives for care, helps track progress, and ensures that the
care plan aligns with the patient’s needs and preferences.
What should a nurse document after a patient’s discharge?
✔✔ Record the discharge instructions given, any follow-up appointments scheduled, and the
patient’s understanding of their post-discharge care plan.
2
, Why is it important to document family involvement in patient care?
✔✔ It acknowledges the role of family in supporting the patient, ensures that family concerns are
addressed, and helps coordinate care with family members.
What are the key components of the nursing process?
✔✔ Assessment, Diagnosis, Planning, Implementation, and Evaluation.
How should a nurse document an assessment finding?
✔✔ Record the observation objectively, include relevant details, and note the date and time of
the assessment.
What is the purpose of nursing diagnosis in the documentation process?
✔✔ To identify and document the patient’s health problems and guide the development of a
personalized care plan.
How should a nurse document the care plan for a patient?
✔✔ Include specific goals, interventions, and expected outcomes, with clear and measurable
terms.
3
Documentation Questions and Answers
Already Passed
What should a nurse document when observing a new wound on a patient?
✔✔ Describe the wound’s size, location, appearance, and any signs of infection, and note when
the wound was first observed.
How does documenting a patient’s nutritional intake contribute to their care?
✔✔ It provides insights into the patient’s dietary needs, helps monitor changes in weight or
health status, and guides adjustments to the care plan.
What should be documented when a patient exhibits an allergic reaction?
✔✔ Record the symptoms, the time of onset, any interventions taken, and the patient’s response
to those interventions.
How can a nurse document the use of assistive devices for a patient?
✔✔ Note the type of device used, the patient’s level of assistance required, and any issues or
improvements observed.
1
,What is the significance of documenting patient consent for medications?
✔✔ It confirms that the patient has been informed about the medication, understands its purpose,
and agrees to its administration.
How should a nurse document the outcome of a patient’s follow-up visit?
✔✔ Include the patient’s progress, any changes in their condition, and updates to the care plan
based on the follow-up assessment.
What information should be included when documenting a patient’s emotional state?
✔✔ Describe observed behaviors, reported feelings, any contributing factors, and how the
emotional state affects the patient’s overall care.
How does documenting patient goals help in the nursing process?
✔✔ It provides clear, measurable objectives for care, helps track progress, and ensures that the
care plan aligns with the patient’s needs and preferences.
What should a nurse document after a patient’s discharge?
✔✔ Record the discharge instructions given, any follow-up appointments scheduled, and the
patient’s understanding of their post-discharge care plan.
2
, Why is it important to document family involvement in patient care?
✔✔ It acknowledges the role of family in supporting the patient, ensures that family concerns are
addressed, and helps coordinate care with family members.
What are the key components of the nursing process?
✔✔ Assessment, Diagnosis, Planning, Implementation, and Evaluation.
How should a nurse document an assessment finding?
✔✔ Record the observation objectively, include relevant details, and note the date and time of
the assessment.
What is the purpose of nursing diagnosis in the documentation process?
✔✔ To identify and document the patient’s health problems and guide the development of a
personalized care plan.
How should a nurse document the care plan for a patient?
✔✔ Include specific goals, interventions, and expected outcomes, with clear and measurable
terms.
3
