RNSG 1513 Foundations of Nursing Exam 2 (2026)
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A manager who is reviewing the D) Enter only objective and factual information
nurses' notes in a patient's medical about the patient.
record finds the following entry,
"Patient is difficult to care for, refuses
suggestion for improving appetite." Nurses should enter only objective and factual
Which of the following directions information about patients. Opinions have no place
does the manager give to the staff in the medical record. Because the information has
nurse who entered the note? already been entered and is not incorrect, it should
A) Avoid rushing when charting an be left on the record. Never use correction fluid in
entry. a written medical record.
B) Use correction fluid to remove the
entry.
C) Draw a single line through the
statement and initial it.
D) Enter only objective and factual
information about the patient.
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A new graduate nurse is providing a B) Gives a newly ordered medication before
telephone report to a patient's health entering the order in the patient's medical record.
care provider and accepting
telephone orders from the provider. Nurses enter orders into the computer or write
Which of the following actions them on the order sheet as they are being given to
requires the new nurse's preceptor to allow the read-back process to occur.
intervene? The new nurse:
A) Uses SBAR (Situation-
Background-Assessment-
Recommendation) as a format when
providing the report.
B) Gives a newly ordered medication
before entering the order in the
patient's medical record.
C) Reads the orders back to the
health care provider after receiving
them and verifies their accuracy.
D) Asks the preceptor to listen in on
the phone conversation.
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As you enter the patient's room, you D. The patient stated that he felt frustrated by the
notice that he is anxious to say lack of information he received regarding his tests.
something. He quickly states, "I don't This is a nonjudgmental statement regarding the
know what's going on; I can't get an nurse's observations about the patient.
explanation from my doctor about Documenting that the patient had a defiant attitude
my test results. I want something or was demanding and frequently complaining is
done about this." Which of the judgmental, and information in the medical record
following is the most appropriate should be factual and nonjudgmental.
documentation of the patient's Documenting that the patient appears upset needs
emotional status? to be more specific regarding the reason for the
A. The patient has a defiant attitude patient's concern.
and is demanding his test results.
B. The patient appears to be upset
with his nurse because he wants his
test results immediately.
C. The patient is demanding and
complains frequently about his
doctor.
D. The patient stated that he felt
frustrated by the lack of information
he received regarding his tests.
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You are reviewing Health Insurance C. HIPAA provides you with greater control over
Portability and Accountability Act your personal health care information.
(HIPAA) regulations with your patient
during the admission process. The
patient states, "I've heard a lot about HIPAA provides patients with control over who
these HIPAA regulations in the news receives and accesses their medical records. It
lately. How will they affect my care?" does not allow uncontrolled access to the medical
Which of the following is the best records. HIPAA also does not dictate what must be
response? documented in the patient's medical record.
A. HIPAA allows all hospital staff
access to your medical record.
B. HIPAA limits the information that is
documented in your medical record.
C. HIPAA provides you with greater
control over your personal health
care information.
D. HIPAA enables health care
institutions to release all of your
personal information to improve
continuity of care.
A patient asks for a copy of her B. Indicate that she has the right to read her record.
medical record. The best response
by the nurse is to:
A. State that only her family may read Patients have the right to read their medical
the record. records, but the nurse should always know the
B. Indicate that she has the right to facility policy regarding personal access to medical
read her record. records because some require a nurse manager or
C. Tell her that she is not allowed to other official to be present to answer questions
read her record. about what is in the record. Families may read the
D. Explain that only health care records only when the patient has given
workers have access to her record. permission.
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