NRSG 91 COMPREHENSIVE EXAM UPDATED QUESTIONS
AND SOLUTIONS GRADED A+
✔✔Who established 1st canadian hospital and what is it called? - ✔✔Hotel dieu-
Jeanne Mance.
✔✔What was florence nightingale missions? - ✔✔to improve hygiene practixes to
decrease the death rate in hospitals.
✔✔What is the purpose of documentation? - ✔✔Facilitation of information flow to
support continuity, quality, and safety of care.
✔✔What is the goal of documentation? - ✔✔To describe facts clearly and concisely to
improve communication.
✔✔What are the characteristics of good documentation? - ✔✔Clear, concise, accurate,
complete, objective, timely, and free of spelling or grammar errors.
✔✔What does EMR stand for? - ✔✔Electronic Medical Records - a record of one
episode of care.
✔✔What does EHR stand for? - ✔✔Electronic Health Records - a longitudinal record of
health that includes in-patient and out-patient documentation.
✔✔What are the common parts of a healthcare record? - ✔✔Patient identification,
informed consent for treatments, medical diagnosis and progress notes, doctors' orders,
nursing database, operative record, discharge plan, and summary.
✔✔What terms should not be used in documentation? - ✔✔Terms like 'seems',
'appears', 'apparently', 'small', 'large', 'usual day', 'good night', 'nice man', 'difficult
patient' should be avoided.
✔✔What must every entry in documentation have? - ✔✔Date, time, full signature, and
correct titles. Only chart care that you have provided.
✔✔How should other patients be referred to in documentation? - ✔✔Instead of using
their names, refer to them as 'patient's room mate'.
✔✔What are the CNO practice standards in regards to documentation? -
✔✔Communication, Accountability, Security
✔✔Communication? - ✔✔Reflects all aspects of the nursing process, legible,
permanent ink, full signature, and designations.
, ✔✔Accountability? - ✔✔:Never delete, alter, or modify another nurse's charts.
✔✔Security? - ✔✔Maintain confidentiality, access only info needed for care, use a
secure line to fax or email patient info.
✔✔What is POMR? - ✔✔Problem-Oriented Medical Record.
✔✔What does PIE stand for? - ✔✔Problem, Intervention, Evaluation.
✔✔What does APIE stand for? - ✔✔Assessment, Problem, Intervention, Evaluation.
✔✔What does SOAP stand for? - ✔✔Subjective, Objective, Assessment, Plan.
✔✔What does SOAPIE or SOAPIER stand for? - ✔✔Subjective, Objective,
Assessment, Plan, Intervention, Evaluation, (Revision/Recommendation).
✔✔What is Focus Charting (DAR)? - ✔✔Data, Action, Response.
✔✔What is Charting by Exception? - ✔✔Recording only abnormal or significant data.
✔✔What is a Kardex? - ✔✔A quick reference with the patient's summary of basic
information.
✔✔What are Critical Pathways or Care Maps? - ✔✔Pre-printed documents with specific
goals, interventions, and time frames. (e.g., pneumonia patient expected to have a 4
day stay)
✔✔What are standardized nursing care plans? - ✔✔Pre-printed established care plans
that should be modified based on the individual's needs.
✔✔What is handoff in healthcare? - ✔✔Passing patient-specific information from one
caregiver to another for continuity of care.
✔✔What should be addressed in a handoff? - ✔✔Care, treatment, services rendered,
current condition, anticipated changes.
✔✔What does SBAR stand for? - ✔✔Situation, Background, Assessment,
Recommendations.
✔✔What does 'Situation' refer to in SBAR? - ✔✔What is happening with the patient.
✔✔What does 'Background' refer to in SBAR? - ✔✔What led to the current situation.
AND SOLUTIONS GRADED A+
✔✔Who established 1st canadian hospital and what is it called? - ✔✔Hotel dieu-
Jeanne Mance.
✔✔What was florence nightingale missions? - ✔✔to improve hygiene practixes to
decrease the death rate in hospitals.
✔✔What is the purpose of documentation? - ✔✔Facilitation of information flow to
support continuity, quality, and safety of care.
✔✔What is the goal of documentation? - ✔✔To describe facts clearly and concisely to
improve communication.
✔✔What are the characteristics of good documentation? - ✔✔Clear, concise, accurate,
complete, objective, timely, and free of spelling or grammar errors.
✔✔What does EMR stand for? - ✔✔Electronic Medical Records - a record of one
episode of care.
✔✔What does EHR stand for? - ✔✔Electronic Health Records - a longitudinal record of
health that includes in-patient and out-patient documentation.
✔✔What are the common parts of a healthcare record? - ✔✔Patient identification,
informed consent for treatments, medical diagnosis and progress notes, doctors' orders,
nursing database, operative record, discharge plan, and summary.
✔✔What terms should not be used in documentation? - ✔✔Terms like 'seems',
'appears', 'apparently', 'small', 'large', 'usual day', 'good night', 'nice man', 'difficult
patient' should be avoided.
✔✔What must every entry in documentation have? - ✔✔Date, time, full signature, and
correct titles. Only chart care that you have provided.
✔✔How should other patients be referred to in documentation? - ✔✔Instead of using
their names, refer to them as 'patient's room mate'.
✔✔What are the CNO practice standards in regards to documentation? -
✔✔Communication, Accountability, Security
✔✔Communication? - ✔✔Reflects all aspects of the nursing process, legible,
permanent ink, full signature, and designations.
, ✔✔Accountability? - ✔✔:Never delete, alter, or modify another nurse's charts.
✔✔Security? - ✔✔Maintain confidentiality, access only info needed for care, use a
secure line to fax or email patient info.
✔✔What is POMR? - ✔✔Problem-Oriented Medical Record.
✔✔What does PIE stand for? - ✔✔Problem, Intervention, Evaluation.
✔✔What does APIE stand for? - ✔✔Assessment, Problem, Intervention, Evaluation.
✔✔What does SOAP stand for? - ✔✔Subjective, Objective, Assessment, Plan.
✔✔What does SOAPIE or SOAPIER stand for? - ✔✔Subjective, Objective,
Assessment, Plan, Intervention, Evaluation, (Revision/Recommendation).
✔✔What is Focus Charting (DAR)? - ✔✔Data, Action, Response.
✔✔What is Charting by Exception? - ✔✔Recording only abnormal or significant data.
✔✔What is a Kardex? - ✔✔A quick reference with the patient's summary of basic
information.
✔✔What are Critical Pathways or Care Maps? - ✔✔Pre-printed documents with specific
goals, interventions, and time frames. (e.g., pneumonia patient expected to have a 4
day stay)
✔✔What are standardized nursing care plans? - ✔✔Pre-printed established care plans
that should be modified based on the individual's needs.
✔✔What is handoff in healthcare? - ✔✔Passing patient-specific information from one
caregiver to another for continuity of care.
✔✔What should be addressed in a handoff? - ✔✔Care, treatment, services rendered,
current condition, anticipated changes.
✔✔What does SBAR stand for? - ✔✔Situation, Background, Assessment,
Recommendations.
✔✔What does 'Situation' refer to in SBAR? - ✔✔What is happening with the patient.
✔✔What does 'Background' refer to in SBAR? - ✔✔What led to the current situation.
