NUR 122 NEW EXAM QUESTIONS AND 100%
CORRECT ANSWERS
Is an essential element of nursing practice. For the purpose of this text, documentation
is defined as anything written or printed within a patient record, which may be paper,
electronic, or a combination of both formats. - ANSWER Documentation
A patient's ____ or chart is a confidential, permanent legal documentation of information
relevant to that patient's health care. - ANSWER record
are oral, written, or audio taped exchanges of information between members of the
health care team. - ANSWER Reports
Your documentation must also meet standards set by the National Comitte for Quality -
ANSWER accreditation
are the basis for establishing reimbursement for patient care. A _____ is a classification
based on patients' medical diagnosis. - ANSWER Diagnosis-related groups (DRG's)
is a problem-oriented approach to documentation. The method is formatted to mirror
the nursing process and encourages communication of patient needs. - ANSWER
problem-orientated medical record
The different disciplines involved in the patient's treatment create a care plan, often
termed an _______ _____ _____, for every problem that has been identified. - ANSWER
Interdiciplinary care plan
S: subjective data (verbalizations of the patient)
O: Objective data - data that are measured and observed.
,A: Assessment- diagnosis based on the subjective and objective data
P: Plan- what the caregiver's plans to do - ANSWER SOAP Note
P: Problem or nursing diagnosis applicable to patient
I : Interventions or actions taken
E: Evaluation of the outcomes of nursing interventions - ANSWER PIE note
____ _____is another form of narrative expression. As the name indicates, it puts less
emphasis on patient problems but focuses on patients' concern like sign or symptom, a
condition, a behavior, or an important event. - ANSWER focus charting
Is a new approach to reduce the time spent in charting. - ANSWER Charting by
exception (CBE)
The ____ _____ ____ of delivering cares utilizes multi-disciplinary approach to
documentation of patient care and concerns about the quality provision of care in
cost-effective ways. - ANSWER Case management plan
Because of the nature of human response, there are _____ in patient outcomes when the
patient deviates from the critical path plan. These ______ are deviations or detours from
the pathway and refer to either positive or negative changes, depending on the clinical
situation. - ANSWER Variances
Flow sheets offer a rapid and convenient reference for evaluating alterations in patient
status. Most critical care units use flow sheets for many types of information. Also used
to see trends over a period of time. - ANSWER Flow sheets
(flip-over card file) maintained at the nurses' station serves as a source of information
for daily patient care. - ANSWER Kardex
An ____ ____ system determines the hours of care for a nursing unit and the number of
staff required to care for a given group of patients. - ANSWER Acuity recording
,A _____ ____ ____ happens any time one health care provider transfers care of a
patient to another health care provider. - ANSWER Hand-off report
The ___ ___ ___ ___ is one type of hand-off report that occurs at the end of each shift. -
ANSWER Change-of-shift report
A ____ ____ is another type of hand-off report that involves communication of information
about patients from the nurse on the sending unit to the nurse on the receiving unit. -
ANSWER transfer report
When there is an actual or potential injury and it is a report that is not a part of the
patient record. - ANSWER Incident report/ occurrence report
is the science and art of turning data into information. - ANSWER Informatics
____ ____ refers to the management and processing of information, generally with the
assistance of computers. - ANSWER Information Technology (IT)
An _____ ______ _____ _______ is a group of systems used within a health care enterprise
that support and enhance health care. - ANSWER Health care information system (HIS)
is defined as a nursing specialty that manages and communicates data, information,
knowledge, and wisdom by integrating nursing, computer, and information science. -
ANSWER Nursing informatics
A ______ is a group of alphanumeric characters that a user enters into the computer
before entering a program. - ANSWER password
A _____ is an integration of hardware and software resources that protects private
network resources, such as a hospital's information system from outside hackers,
, network damage, and theft or misuse of information. - ANSWER Firewall
is one of the types of order entry systems that is very increasingly used in the large
medical centers across the country, especially with medication orders. - ANSWER
computerized provider order entry (CPOE)
The ____ ____ ___ is an longitudinal electronic record of patient health information
generated by one or more encounters in any care delivery setting. It ensures
coordination of care because all primary caregivers can view a common record of a
patient's entire health care experience including inpatient, outpatient, and emergency
care. - ANSWER electronic health record (EHR)
What are examples of Focus charting? - ANSWER D-Data P-Problem
A-Action I-Intervention
R-Response E-Evaluation
What is inspection? ANSWER It is the use of vision and hearing to distinguish normal
from abnormal findings.
What is palpation? When does this typically occur? ANSWER It refers to the use of the
hands to touch body parts to make sensitive assessments. This typically occurs right
after inspection.
What is percussion? What does the character of the sound determine? __________
involves tapping the body with the finger tips to produce a vibration that travels through
body tissues. The character of the sound determines the location, size, and density of
underlying structures.to verify abnormalities assessed by palpation and auscultation.
What is Auscultation? But what do you first need to learn before assessing for this? -
ANSWER ______ is listening with a stethoscope to sounds produced by the body. First
learn the normal sounds the cardiovascular, respiratory, and GI systems make, such as
movement of air through the lungs.
CORRECT ANSWERS
Is an essential element of nursing practice. For the purpose of this text, documentation
is defined as anything written or printed within a patient record, which may be paper,
electronic, or a combination of both formats. - ANSWER Documentation
A patient's ____ or chart is a confidential, permanent legal documentation of information
relevant to that patient's health care. - ANSWER record
are oral, written, or audio taped exchanges of information between members of the
health care team. - ANSWER Reports
Your documentation must also meet standards set by the National Comitte for Quality -
ANSWER accreditation
are the basis for establishing reimbursement for patient care. A _____ is a classification
based on patients' medical diagnosis. - ANSWER Diagnosis-related groups (DRG's)
is a problem-oriented approach to documentation. The method is formatted to mirror
the nursing process and encourages communication of patient needs. - ANSWER
problem-orientated medical record
The different disciplines involved in the patient's treatment create a care plan, often
termed an _______ _____ _____, for every problem that has been identified. - ANSWER
Interdiciplinary care plan
S: subjective data (verbalizations of the patient)
O: Objective data - data that are measured and observed.
,A: Assessment- diagnosis based on the subjective and objective data
P: Plan- what the caregiver's plans to do - ANSWER SOAP Note
P: Problem or nursing diagnosis applicable to patient
I : Interventions or actions taken
E: Evaluation of the outcomes of nursing interventions - ANSWER PIE note
____ _____is another form of narrative expression. As the name indicates, it puts less
emphasis on patient problems but focuses on patients' concern like sign or symptom, a
condition, a behavior, or an important event. - ANSWER focus charting
Is a new approach to reduce the time spent in charting. - ANSWER Charting by
exception (CBE)
The ____ _____ ____ of delivering cares utilizes multi-disciplinary approach to
documentation of patient care and concerns about the quality provision of care in
cost-effective ways. - ANSWER Case management plan
Because of the nature of human response, there are _____ in patient outcomes when the
patient deviates from the critical path plan. These ______ are deviations or detours from
the pathway and refer to either positive or negative changes, depending on the clinical
situation. - ANSWER Variances
Flow sheets offer a rapid and convenient reference for evaluating alterations in patient
status. Most critical care units use flow sheets for many types of information. Also used
to see trends over a period of time. - ANSWER Flow sheets
(flip-over card file) maintained at the nurses' station serves as a source of information
for daily patient care. - ANSWER Kardex
An ____ ____ system determines the hours of care for a nursing unit and the number of
staff required to care for a given group of patients. - ANSWER Acuity recording
,A _____ ____ ____ happens any time one health care provider transfers care of a
patient to another health care provider. - ANSWER Hand-off report
The ___ ___ ___ ___ is one type of hand-off report that occurs at the end of each shift. -
ANSWER Change-of-shift report
A ____ ____ is another type of hand-off report that involves communication of information
about patients from the nurse on the sending unit to the nurse on the receiving unit. -
ANSWER transfer report
When there is an actual or potential injury and it is a report that is not a part of the
patient record. - ANSWER Incident report/ occurrence report
is the science and art of turning data into information. - ANSWER Informatics
____ ____ refers to the management and processing of information, generally with the
assistance of computers. - ANSWER Information Technology (IT)
An _____ ______ _____ _______ is a group of systems used within a health care enterprise
that support and enhance health care. - ANSWER Health care information system (HIS)
is defined as a nursing specialty that manages and communicates data, information,
knowledge, and wisdom by integrating nursing, computer, and information science. -
ANSWER Nursing informatics
A ______ is a group of alphanumeric characters that a user enters into the computer
before entering a program. - ANSWER password
A _____ is an integration of hardware and software resources that protects private
network resources, such as a hospital's information system from outside hackers,
, network damage, and theft or misuse of information. - ANSWER Firewall
is one of the types of order entry systems that is very increasingly used in the large
medical centers across the country, especially with medication orders. - ANSWER
computerized provider order entry (CPOE)
The ____ ____ ___ is an longitudinal electronic record of patient health information
generated by one or more encounters in any care delivery setting. It ensures
coordination of care because all primary caregivers can view a common record of a
patient's entire health care experience including inpatient, outpatient, and emergency
care. - ANSWER electronic health record (EHR)
What are examples of Focus charting? - ANSWER D-Data P-Problem
A-Action I-Intervention
R-Response E-Evaluation
What is inspection? ANSWER It is the use of vision and hearing to distinguish normal
from abnormal findings.
What is palpation? When does this typically occur? ANSWER It refers to the use of the
hands to touch body parts to make sensitive assessments. This typically occurs right
after inspection.
What is percussion? What does the character of the sound determine? __________
involves tapping the body with the finger tips to produce a vibration that travels through
body tissues. The character of the sound determines the location, size, and density of
underlying structures.to verify abnormalities assessed by palpation and auscultation.
What is Auscultation? But what do you first need to learn before assessing for this? -
ANSWER ______ is listening with a stethoscope to sounds produced by the body. First
learn the normal sounds the cardiovascular, respiratory, and GI systems make, such as
movement of air through the lungs.
