Nursing 100 Exam 3 Questions with
Correct Answers
A manager is reviewing the nursing documentation entered by a staff nurse in a
patient's electronic medical record and finds the following entry, "Patient is difficult to
care for, refuses suggestion for improving appetite." Which of the following statements
is most appropriate for the manager to make to the staff nurse who entered this
information?
1. "Avoid rushing when documenting an entry in the medical record."
2. "Use correction fluid to remove the entry."
3. " Draw a single line through the statement and initial it."
4. Enter only objective and factual info about a patient in the medical record - Answer-4-
Nurses should enter only objective and factual info about patients. Opinions have no
place in the medical record. Because the info has already been entered and is no
incorrect, it should be left on the record
A preceptor observes a new graduate nurse discussing changes in a patient's
conditions with a physician over the phone. The new graduate nurse accepts telephone
orders for a new medication and for some lab tests from the physician at the end of the
conversation. During the conversation the new grad writes the orders on a piece of
paper to enter them into the electronic medical record when a computer terminal is
available. At this hospital new medication orders entered into the electronic medical
record can be viewed immediately by hospital pharmacists, and hospital policy states
that all new medications must be reviewed by a pharmacist before being administered
to patients. Which of the following actions requires the preceptor to intervene?
1. Reads the orders back to the health care provider to verify accuracy of transcribing
the orders after receiving them over the phone
2. Documents the date and time of the phone - Answer-3- When provider orders for new
medications are entered into an electronic medical record, the new orders are available
to pharmacists using the same electronic system within the hospital. To improve patient
safety, many hospitals have a policy that new medications are not to be administered
until a pharmacist reviews the new orders, and verifies that there is no document
allergies to the medications, the ordered doses are appropriate, and that there are no
potential medication interactions with medications already ordered for a patient. Nurse
enter orders into the computer or write them on the order sheet as they are being given
to allow the read-back process to occur
As the nurse enters a patient's room, the nurse notices that the patient is anxious. The
patient quickly states, " I don't know what's going on: I can't get an explanation from my
doctor about my test results. I want something done about this." Which of the following
is the most appropriate way for the nurse to document this observation of he patient?
1. "The patient has a defiant attitude and is demanding test results."
2. "The patient appears to be upset with the nurse because he wants his test results
immediately."
, 3. "The patient is demanding and is complaining about the doctor."
4. "The patient stated feelings of frustration from the lack of info received regarding test
results." - Answer-4- This is a nonjudgmental statement regarding the nurse's
observations about the patient. Documenting that the patient has a defiant attitude or is
demanding is judgmental, and info in the medical record should be factual and
nonjudgmental. Noting that the patient appears upset with the nurse needs to be more
specific; it does not provide enough info regarding the reason for the patient's concerns
The nurse is reviewing the HIPAA regulations with the patient during the admission
process. The patient states, "I'm not familiar with these HIPAA regulations. How will
they affect my care?" Which of the following is the best response?
1. HIPAA allows hospital staff access to your medical record
2. HIPAA limits the info that is documented in your medical record
3. HIPAA provides you with greater protection of you personal health info
4. HIPAA enables health care institutions to release all of your personal info to improve
continuity of care - Answer-3- HIPAA provides patients with control over who receives
and accesses their medical records. It does not allow uncontrolled access to the
medical records. HIPAA also does not dictate what must be documented in the patien'ts
medical record
A patient states, "I would like to see what is written in my medical record." What is the
nurse's best response?
1. "Only your family can read your medical record"
2. "You have the right to read your record"
3. "Patient's are not allowed to read their records"
4. "Only health care workers have access to patient records" - Answer-2- Patients have
the right to read their medical records, but the nurse should always know the facility
policy regarding personal access to medical records because some require a nurse
manager or other official to be present to answer questions about what is in the record.
Families may read the records only when the patient has given permission
Which of the following documentation entries is most accurate?
1. "Patient walked up and down hallway with assistance, tolerated well."
2. "Patient up, out of bed, walked down hallway and back to room, tolerated well."
3. "Patient up, walked 50 feet and back down hallway with assistance from nurse.
Spouse also accompanied patient during the walk."
4. "Patient walked 50 feet and back down hallway with assistance from nurse: HR 88
and regular before exercise, HR 94 and regular following exercise" - Answer-4-This
provides the most accurate, objective info for the chart
Label each line of documentation with the appropriate SOAP category.
1. Re-positioned patient on right-side. Encouraged patient to use patient-controlled
analgesia (PCA) devise
2. "The pain increases every time I try to turn on my left side."
3. Acute pain related to tissue injury from surgical incision
Correct Answers
A manager is reviewing the nursing documentation entered by a staff nurse in a
patient's electronic medical record and finds the following entry, "Patient is difficult to
care for, refuses suggestion for improving appetite." Which of the following statements
is most appropriate for the manager to make to the staff nurse who entered this
information?
1. "Avoid rushing when documenting an entry in the medical record."
2. "Use correction fluid to remove the entry."
3. " Draw a single line through the statement and initial it."
4. Enter only objective and factual info about a patient in the medical record - Answer-4-
Nurses should enter only objective and factual info about patients. Opinions have no
place in the medical record. Because the info has already been entered and is no
incorrect, it should be left on the record
A preceptor observes a new graduate nurse discussing changes in a patient's
conditions with a physician over the phone. The new graduate nurse accepts telephone
orders for a new medication and for some lab tests from the physician at the end of the
conversation. During the conversation the new grad writes the orders on a piece of
paper to enter them into the electronic medical record when a computer terminal is
available. At this hospital new medication orders entered into the electronic medical
record can be viewed immediately by hospital pharmacists, and hospital policy states
that all new medications must be reviewed by a pharmacist before being administered
to patients. Which of the following actions requires the preceptor to intervene?
1. Reads the orders back to the health care provider to verify accuracy of transcribing
the orders after receiving them over the phone
2. Documents the date and time of the phone - Answer-3- When provider orders for new
medications are entered into an electronic medical record, the new orders are available
to pharmacists using the same electronic system within the hospital. To improve patient
safety, many hospitals have a policy that new medications are not to be administered
until a pharmacist reviews the new orders, and verifies that there is no document
allergies to the medications, the ordered doses are appropriate, and that there are no
potential medication interactions with medications already ordered for a patient. Nurse
enter orders into the computer or write them on the order sheet as they are being given
to allow the read-back process to occur
As the nurse enters a patient's room, the nurse notices that the patient is anxious. The
patient quickly states, " I don't know what's going on: I can't get an explanation from my
doctor about my test results. I want something done about this." Which of the following
is the most appropriate way for the nurse to document this observation of he patient?
1. "The patient has a defiant attitude and is demanding test results."
2. "The patient appears to be upset with the nurse because he wants his test results
immediately."
, 3. "The patient is demanding and is complaining about the doctor."
4. "The patient stated feelings of frustration from the lack of info received regarding test
results." - Answer-4- This is a nonjudgmental statement regarding the nurse's
observations about the patient. Documenting that the patient has a defiant attitude or is
demanding is judgmental, and info in the medical record should be factual and
nonjudgmental. Noting that the patient appears upset with the nurse needs to be more
specific; it does not provide enough info regarding the reason for the patient's concerns
The nurse is reviewing the HIPAA regulations with the patient during the admission
process. The patient states, "I'm not familiar with these HIPAA regulations. How will
they affect my care?" Which of the following is the best response?
1. HIPAA allows hospital staff access to your medical record
2. HIPAA limits the info that is documented in your medical record
3. HIPAA provides you with greater protection of you personal health info
4. HIPAA enables health care institutions to release all of your personal info to improve
continuity of care - Answer-3- HIPAA provides patients with control over who receives
and accesses their medical records. It does not allow uncontrolled access to the
medical records. HIPAA also does not dictate what must be documented in the patien'ts
medical record
A patient states, "I would like to see what is written in my medical record." What is the
nurse's best response?
1. "Only your family can read your medical record"
2. "You have the right to read your record"
3. "Patient's are not allowed to read their records"
4. "Only health care workers have access to patient records" - Answer-2- Patients have
the right to read their medical records, but the nurse should always know the facility
policy regarding personal access to medical records because some require a nurse
manager or other official to be present to answer questions about what is in the record.
Families may read the records only when the patient has given permission
Which of the following documentation entries is most accurate?
1. "Patient walked up and down hallway with assistance, tolerated well."
2. "Patient up, out of bed, walked down hallway and back to room, tolerated well."
3. "Patient up, walked 50 feet and back down hallway with assistance from nurse.
Spouse also accompanied patient during the walk."
4. "Patient walked 50 feet and back down hallway with assistance from nurse: HR 88
and regular before exercise, HR 94 and regular following exercise" - Answer-4-This
provides the most accurate, objective info for the chart
Label each line of documentation with the appropriate SOAP category.
1. Re-positioned patient on right-side. Encouraged patient to use patient-controlled
analgesia (PCA) devise
2. "The pain increases every time I try to turn on my left side."
3. Acute pain related to tissue injury from surgical incision
