Chapter 07: Documentation of Nursing Care
MULTIPLE CHOICE
1. The nurse is with a patient who complains of severe pain, documents every 15 minutes about
the steps taken to try to relieve the pain (without success). The nurse also documents the time
and content of two calls made to the patient’s primary care provider requesting that the
primary care provider examines the patient for unexpected complications. This documentation
by the nurse is likely to:
a. cause the primary care provider to come to the attention of the hospital
administration.
b. be questioned by the nurse’s supervisor for time inefficiency.
c. be used against the nurse if a lawsuit results, because it proves the nurse was not
able to relieve the pain.
d. justify insurance reimbursement for an extended duration of hospitalization for the
patient.
ANS: D
Documentation of complications or a patient’s changing condition is used by insurance
companies to justify payments for hospitalization. Documentation also serves as evidence of
standards of care in a court of law.
DIF: Cognitive Level: Application REF: p. 84 OBJ: Theory #4
TOP: Purposes of Documentation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological IntegrN itU
y:RBSaIN
siG
c TCBa.rCeOaM
nd Comfort
2. A patient who is very angry and is leaving the hospital against medical advice (AMA)
demands to have the medical record to take, because it is her personal property. An
appropriate response would be:
a. “Certainly. This hospital doesn’t need to keep it if you are leaving and will not be
returning here.”
b. “You are entitled to the information in your medical record, but the medical record
is the property of the hospital. I will see about having a copy made for you.”
c. “The information in your medical record is confidential, and you cannot leave this
facility with it.”
d. “Because you are leaving against the medical advice of your primary care
provider, you may not have the medical record.”
ANS: B
The medical record is the property of the facility, but the patient has a legal right to the
information in it even if she is leaving AMA.
DIF: Cognitive Level: Application REF: p. 86 OBJ: Theory #3
TOP: The Medical Record KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. A student nurse is assigned to a clinical unit on which one of the patients is a nationally
known celebrity. The student reads the chart to find out why the celebrity is being treated. The
student who is not the assigned caregiver is:
, a. motivated to learn about the health problem of this patient and is appropriately
seeking knowledge during his clinical experience.
b. doing appropriate research about nursing care as long as information is not
divulged.
c. violating the confidentiality of the patient’s record.
d. neglecting the assigned patient load and should read the unassigned patient’s
medical record only after his assigned work is completed.
ANS: C
A person reading a patient’s chart who is not involved in the patient’s care is in violation of
confidentiality. Protecting the patient’s privacy is of prime importance.
DIF: Cognitive Level: Comprehension REF: p. 92 OBJ: Theory #3
TOP: The Medical Record KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
4. A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced
by disruption of skin surface has the following nursing documentation: “Incision clean, dry,
intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect
from clothing. Verbalizes understanding of wound care and ability to manage at home.
Wound healing without complication.” This documentation is:
a. an example of charting by exception.
b. evidence of the use of the nursing process.
c. using the problem-oriented medical record (POMR) format.
d. usually entered on a flow sheet for treatments and vital signs.
ANS: B
The nursing process is evident in tNhUisRdSoINcGTBe.nCtO
um atM
ion. Assessment, interventions, and
evaluation are all noted.
DIF: Cognitive Level: Analysis REF: p. 92 OBJ: Theory #2
TOP: Methods of Charting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. Which nursing assessment is an example of brevity and clarity while meeting legal
guidelines?
a. “4 cm reddened area over sacrum. Skin intact, warm, and dry.”
b. “Taking fluids poorly, but more than yesterday.”
c. “Apparently comfortable all night. Offers no complaints of pain.”
d. “Patient says she is still slightly nauseated, would like to try some toast and tea.”
ANS: A
Provision of specific objective data—size, location, and characteristics of the patient’s
skin—is clear and brief and informative.
DIF: Cognitive Level: Comprehension REF: p. 95 OBJ: Clinical Practice #2
TOP: The Charting Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. A nurse enters a notation in a patient’s medical record but then discovers that the notation was
made in the wrong chart. The nurse correctly:
a. draws a single line through the notation so that it is still readable and writes
MULTIPLE CHOICE
1. The nurse is with a patient who complains of severe pain, documents every 15 minutes about
the steps taken to try to relieve the pain (without success). The nurse also documents the time
and content of two calls made to the patient’s primary care provider requesting that the
primary care provider examines the patient for unexpected complications. This documentation
by the nurse is likely to:
a. cause the primary care provider to come to the attention of the hospital
administration.
b. be questioned by the nurse’s supervisor for time inefficiency.
c. be used against the nurse if a lawsuit results, because it proves the nurse was not
able to relieve the pain.
d. justify insurance reimbursement for an extended duration of hospitalization for the
patient.
ANS: D
Documentation of complications or a patient’s changing condition is used by insurance
companies to justify payments for hospitalization. Documentation also serves as evidence of
standards of care in a court of law.
DIF: Cognitive Level: Application REF: p. 84 OBJ: Theory #4
TOP: Purposes of Documentation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological IntegrN itU
y:RBSaIN
siG
c TCBa.rCeOaM
nd Comfort
2. A patient who is very angry and is leaving the hospital against medical advice (AMA)
demands to have the medical record to take, because it is her personal property. An
appropriate response would be:
a. “Certainly. This hospital doesn’t need to keep it if you are leaving and will not be
returning here.”
b. “You are entitled to the information in your medical record, but the medical record
is the property of the hospital. I will see about having a copy made for you.”
c. “The information in your medical record is confidential, and you cannot leave this
facility with it.”
d. “Because you are leaving against the medical advice of your primary care
provider, you may not have the medical record.”
ANS: B
The medical record is the property of the facility, but the patient has a legal right to the
information in it even if she is leaving AMA.
DIF: Cognitive Level: Application REF: p. 86 OBJ: Theory #3
TOP: The Medical Record KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. A student nurse is assigned to a clinical unit on which one of the patients is a nationally
known celebrity. The student reads the chart to find out why the celebrity is being treated. The
student who is not the assigned caregiver is:
, a. motivated to learn about the health problem of this patient and is appropriately
seeking knowledge during his clinical experience.
b. doing appropriate research about nursing care as long as information is not
divulged.
c. violating the confidentiality of the patient’s record.
d. neglecting the assigned patient load and should read the unassigned patient’s
medical record only after his assigned work is completed.
ANS: C
A person reading a patient’s chart who is not involved in the patient’s care is in violation of
confidentiality. Protecting the patient’s privacy is of prime importance.
DIF: Cognitive Level: Comprehension REF: p. 92 OBJ: Theory #3
TOP: The Medical Record KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
4. A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced
by disruption of skin surface has the following nursing documentation: “Incision clean, dry,
intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect
from clothing. Verbalizes understanding of wound care and ability to manage at home.
Wound healing without complication.” This documentation is:
a. an example of charting by exception.
b. evidence of the use of the nursing process.
c. using the problem-oriented medical record (POMR) format.
d. usually entered on a flow sheet for treatments and vital signs.
ANS: B
The nursing process is evident in tNhUisRdSoINcGTBe.nCtO
um atM
ion. Assessment, interventions, and
evaluation are all noted.
DIF: Cognitive Level: Analysis REF: p. 92 OBJ: Theory #2
TOP: Methods of Charting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. Which nursing assessment is an example of brevity and clarity while meeting legal
guidelines?
a. “4 cm reddened area over sacrum. Skin intact, warm, and dry.”
b. “Taking fluids poorly, but more than yesterday.”
c. “Apparently comfortable all night. Offers no complaints of pain.”
d. “Patient says she is still slightly nauseated, would like to try some toast and tea.”
ANS: A
Provision of specific objective data—size, location, and characteristics of the patient’s
skin—is clear and brief and informative.
DIF: Cognitive Level: Comprehension REF: p. 95 OBJ: Clinical Practice #2
TOP: The Charting Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. A nurse enters a notation in a patient’s medical record but then discovers that the notation was
made in the wrong chart. The nurse correctly:
a. draws a single line through the notation so that it is still readable and writes
