PNU 116 PrePU ChaPter 19: DoCUmeNtiNg aND rePortiNg exam Newest
2025/2026 with ComPlete QUestioNs aND CorreCt aNswers |alreaDy
graDeD a+||BraND New VersioN!
A nurse manager is discussing a nurse's social media post about an interesting client
situation. The nurse states, "I didn't violate client privacy because I didn't use the client's
name." What response by the nurse manager is most appropriate? - DETAILED ANSWER -"Any
information that can identify a person is considered a breach of client privacy."
The nurses at a health care facility were informed of the change to organize the clients'
records into problem-oriented records. Which explanation could assist the nurses in
determining the advantage of using problem-oriented records? - DETAILED ANSWER -Problem-
oriented recording emphasizes goal-directed care to promote the recording of pertinent
data that will facilitate communication among health care providers.
The parents of a hospitalized 10-year-old ask the nurse if they can review the health care
records of their child. What is the appropriate response from the nurse? - DETAILED ANSWER -"I
will arrange access for you to review the record after you put your request in writing."
A client made a formal request to review his or her medical records. With review, the
client believes there are errors within the medical record. What is the most appropriate
nursing response? - DETAILED ANSWER -"According to HIPAA legislation, you have a right to
request changes to inaccurate information." Which nurse-to-provider interaction
correctly utilizes the SBAR format for improved communication? - DETAILED ANSWER -"I am
calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250
mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale
insulin."
, The nurse calls the health care provider due to changes in the client's status. Using the
SBAR, the nurse is about to address Recommendation. Which statement appropriately
supports this part of the SBAR? - DETAILED ANSWER -"Will you prescribe a complete blood
count to check the white blood cell count and a culture?"
A nurse is working with the case management model and using a collaborative pathway.
The nurse notes that the client has not met an expected outcome and documents this
using occurrence charting. When completing this documentation, what information
would the nurse include? Select all that apply. - DETAILED ANSWER -Unexpected event
Cause of the event
Actions taken in response to the event
A client is scheduled for a CABG procedure. What information should the nurse provide
to the client? - DETAILED ANSWER -"A coronary artery bypass graft will benefit your heart."
A nurse is transfusing multiple units of packed red blood cells. After the second unit is
transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and
the client reports dyspnea. The nurse telephones the health care provider and provides
an SBAR report. Which statement represents the final step in this type of
communication? - DETAILED ANSWER -"I think the client would benefit from intravenous
furosemide."
The nurse is reassessing a client after pain medication has been administered to manage
the pain from a bilateral knee replacement procedure. Which statement most accurately
depicts proper documentation of pain assessment? - DETAILED ANSWER -The client reports
that on a scale of 0 to 10, the current pain is a 3.
Which statement about client records and documentation is correct? - DETAILED ANSWER
Communication is the primary purpose of client records.
2025/2026 with ComPlete QUestioNs aND CorreCt aNswers |alreaDy
graDeD a+||BraND New VersioN!
A nurse manager is discussing a nurse's social media post about an interesting client
situation. The nurse states, "I didn't violate client privacy because I didn't use the client's
name." What response by the nurse manager is most appropriate? - DETAILED ANSWER -"Any
information that can identify a person is considered a breach of client privacy."
The nurses at a health care facility were informed of the change to organize the clients'
records into problem-oriented records. Which explanation could assist the nurses in
determining the advantage of using problem-oriented records? - DETAILED ANSWER -Problem-
oriented recording emphasizes goal-directed care to promote the recording of pertinent
data that will facilitate communication among health care providers.
The parents of a hospitalized 10-year-old ask the nurse if they can review the health care
records of their child. What is the appropriate response from the nurse? - DETAILED ANSWER -"I
will arrange access for you to review the record after you put your request in writing."
A client made a formal request to review his or her medical records. With review, the
client believes there are errors within the medical record. What is the most appropriate
nursing response? - DETAILED ANSWER -"According to HIPAA legislation, you have a right to
request changes to inaccurate information." Which nurse-to-provider interaction
correctly utilizes the SBAR format for improved communication? - DETAILED ANSWER -"I am
calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250
mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale
insulin."
, The nurse calls the health care provider due to changes in the client's status. Using the
SBAR, the nurse is about to address Recommendation. Which statement appropriately
supports this part of the SBAR? - DETAILED ANSWER -"Will you prescribe a complete blood
count to check the white blood cell count and a culture?"
A nurse is working with the case management model and using a collaborative pathway.
The nurse notes that the client has not met an expected outcome and documents this
using occurrence charting. When completing this documentation, what information
would the nurse include? Select all that apply. - DETAILED ANSWER -Unexpected event
Cause of the event
Actions taken in response to the event
A client is scheduled for a CABG procedure. What information should the nurse provide
to the client? - DETAILED ANSWER -"A coronary artery bypass graft will benefit your heart."
A nurse is transfusing multiple units of packed red blood cells. After the second unit is
transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and
the client reports dyspnea. The nurse telephones the health care provider and provides
an SBAR report. Which statement represents the final step in this type of
communication? - DETAILED ANSWER -"I think the client would benefit from intravenous
furosemide."
The nurse is reassessing a client after pain medication has been administered to manage
the pain from a bilateral knee replacement procedure. Which statement most accurately
depicts proper documentation of pain assessment? - DETAILED ANSWER -The client reports
that on a scale of 0 to 10, the current pain is a 3.
Which statement about client records and documentation is correct? - DETAILED ANSWER
Communication is the primary purpose of client records.
