RNSG 1105 ACTUAL 2026 STUDY GUIDE QUESTIONS AND
SOLUTIONS RATED A+
✔✔HIPAA - ✔✔provides rights to pts and protects employees; creates pt right to
consent to the use and disclosure of their protected health information, to inspect and
copy one's medical record, and to amend mistaken or incomplete information
Limits who is able to access a pt's record; provides confidentiality of a pt's medical
record
✔✔Health Information Technology Act (HITECH) - ✔✔expands principles under HIPAA,
especially when a breach of personal health information occurs; nurses must ensure
that pt PHI is not inadvertently conveyed on social media and that protected data are
not disclosed other than as permitted by the pt
✔✔Purposes of documentation in the pt's medical chart - ✔✔communication
legal and historical documentation
reimbursement
auditing and monitoring
research; data analysis
education
✔✔Legal Guidelines for Documentation - ✔✔do not document critical comments made
about a pt or care provided by another healthcare professional
do not enter personal opinions
correct all errors promptly
record all facts
document discussions with HCPs that you initiate to seek clarification
document only for yourself
avoid using generalized, empty phrases
begin each entry with date and time and end with your credentials
protect the security of your password for computer documentation
✔✔SBAR - ✔✔Situation: who/where/why
Background: summary of pt history
Assessment: clinical information
Recommendation: advice about what to do next
✔✔Benefits of Health Informatics - Clinical information systems - ✔✔provides a vehicle
for improving quality and safety of pt care
provides a basic level of interoperability among EHRs
stimulates consumer education and pt's involvement
helps public health officials meet their commitment to communtiy
✔✔Benefits of Health Informatics - Administrative information systems - ✔✔increases in
the accuracy and completeness of nursing documentation
, improvement in the nurse's workflow and an elimination of redundant documentation
automation of the collection and reuse of nursing data
facilitation of the analysis of clinical data
✔✔Institute of Medicine - ✔✔Health division of National Academy of Sciences. National
advisor on matters R/T health improvement
✔✔Quality and Safety Education for Nurses (QSEN) - ✔✔addresses the challenge to
prepare nurses with the competencies needed to continuously improve the quality of
care in their work environments
✔✔General risk factors for falls - ✔✔age - over 65 years old
previous falls
lifestyle
impaired mobility
sensory or communication impairment
lack of safety awareness
✔✔Risk factors for falls in the home - ✔✔inadequate lighting
barriers in pathways and stairways
loose rugs and carpeting
lack of safety devices in the home
✔✔Risk factors for falls in a health care agency - ✔✔poor lighting
high bed position
improper equipment
unfamiliar environment
✔✔Hendrich II Assessment - ✔✔score is totaled, indicating level of risk score: 0-4 low
risk; 5 or greater high risk; if category changes, interventions for new category must be
implemented
✔✔Low Risk for fall interventions - ✔✔top side rails up at all times
Keep bed in low position
verify call light within reach at all times
bedside table within reach at all times with frequently needed items
light source turned on
verify non-skid footwear within reach
offer to assist with toileting whenever in room, if needed
teach fall prevention techniques
assess the 4 P's each time prior to leaving the pt's room
✔✔High Risk for falls interventions - ✔✔low risk interventions as appropriate
bed alarms, chair alarms when available
ensure visual alerts in place (yellow bracelet or socks)
SOLUTIONS RATED A+
✔✔HIPAA - ✔✔provides rights to pts and protects employees; creates pt right to
consent to the use and disclosure of their protected health information, to inspect and
copy one's medical record, and to amend mistaken or incomplete information
Limits who is able to access a pt's record; provides confidentiality of a pt's medical
record
✔✔Health Information Technology Act (HITECH) - ✔✔expands principles under HIPAA,
especially when a breach of personal health information occurs; nurses must ensure
that pt PHI is not inadvertently conveyed on social media and that protected data are
not disclosed other than as permitted by the pt
✔✔Purposes of documentation in the pt's medical chart - ✔✔communication
legal and historical documentation
reimbursement
auditing and monitoring
research; data analysis
education
✔✔Legal Guidelines for Documentation - ✔✔do not document critical comments made
about a pt or care provided by another healthcare professional
do not enter personal opinions
correct all errors promptly
record all facts
document discussions with HCPs that you initiate to seek clarification
document only for yourself
avoid using generalized, empty phrases
begin each entry with date and time and end with your credentials
protect the security of your password for computer documentation
✔✔SBAR - ✔✔Situation: who/where/why
Background: summary of pt history
Assessment: clinical information
Recommendation: advice about what to do next
✔✔Benefits of Health Informatics - Clinical information systems - ✔✔provides a vehicle
for improving quality and safety of pt care
provides a basic level of interoperability among EHRs
stimulates consumer education and pt's involvement
helps public health officials meet their commitment to communtiy
✔✔Benefits of Health Informatics - Administrative information systems - ✔✔increases in
the accuracy and completeness of nursing documentation
, improvement in the nurse's workflow and an elimination of redundant documentation
automation of the collection and reuse of nursing data
facilitation of the analysis of clinical data
✔✔Institute of Medicine - ✔✔Health division of National Academy of Sciences. National
advisor on matters R/T health improvement
✔✔Quality and Safety Education for Nurses (QSEN) - ✔✔addresses the challenge to
prepare nurses with the competencies needed to continuously improve the quality of
care in their work environments
✔✔General risk factors for falls - ✔✔age - over 65 years old
previous falls
lifestyle
impaired mobility
sensory or communication impairment
lack of safety awareness
✔✔Risk factors for falls in the home - ✔✔inadequate lighting
barriers in pathways and stairways
loose rugs and carpeting
lack of safety devices in the home
✔✔Risk factors for falls in a health care agency - ✔✔poor lighting
high bed position
improper equipment
unfamiliar environment
✔✔Hendrich II Assessment - ✔✔score is totaled, indicating level of risk score: 0-4 low
risk; 5 or greater high risk; if category changes, interventions for new category must be
implemented
✔✔Low Risk for fall interventions - ✔✔top side rails up at all times
Keep bed in low position
verify call light within reach at all times
bedside table within reach at all times with frequently needed items
light source turned on
verify non-skid footwear within reach
offer to assist with toileting whenever in room, if needed
teach fall prevention techniques
assess the 4 P's each time prior to leaving the pt's room
✔✔High Risk for falls interventions - ✔✔low risk interventions as appropriate
bed alarms, chair alarms when available
ensure visual alerts in place (yellow bracelet or socks)
