EXAM 2026-2027 ACTUAL COMPLETE QUESTIONS FREQUENTLY
MOST TESTED REAL EXAM QUESTIONS AND VERIFIED SOLUTIONS |
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A nurse is discussing the HIPAA Privacy Rule with nurses during new employee
orientation. Which of the following information should the nurse include? (Select all
that apply)
1. A single electronic records password is provided for nurses on the same unit.
2. Family members should provide a code prior to receiving client health
information.
3. Communication of information can occur at the nurses' station.
4. A client can request a copy of her medical record
5. A nurse may photocopy a client's medical record for transfer to another facility.
1T
2T
3T
4T
5F
,Progress Notes:
-Think of it as connecting the dots between the remainder of your
documentation.
-No need to document information that can already be found elsewhere in the
EMR
-Plan of care
TRUE
Anything abnormal or unexpected should be documented
Rapid Response, Code Blue, Code Man, Acute change in status-decreased LOC,
increase oxygen needs, sudden onset pain, Patient fall, etc.
You MUST then document what you did to ____ the abnormal or unexpected
situation
resolve
SOAP
subjective, objective, assessment, plan
Utilizes nursing process and includes nursing diagnosis
SOAP
,"I'm worried about the surgery. Last time I had a lot of pain when I got out of
bed."
S
Asking multiple questions about how post op pain will be addressed.
O
Anxiety related perceived threat of postoperative pain as evidenced by
statement of prior experience with uncontrolled postop pain
A
Explain routine postop analgesic plan of care. Encourage nursing staff as soon as
possible if pain is not relieved. Explain rationale for early postoperative
ambulation and demonstrate TCDB exercises.
P
PIE
problem-intervention-evaluation
: Starts with nursing diagnosis. Unifies care plan and progress note. Does not
include assessment information.
PIE
, Anxiety related perceived threat of postoperative pain as evidenced by
statement of prior experience with uncontrolled postop pain
P
Explained importance of post op ambulation and demonstrated TCDB exercises.
Described analgesic plan of care.
I
Stated "I feel less anxious about postoperative pain now" and performed return
demonstration of TCDB exercises correctly. Needs review of post op plan of
care.
E
Method traditionally used to record patient assessment and nursing care
provided. Story like format. Tends to be time consuming. Hard to sort through
information.
narrative note
FDAR
focus charting data-action-reponse