NSG 3130 EXAM 4 TEST PREPARATION
QUESTIONS AND COMPLETE RESPONSE
GUIDE
●● What is necessary for hospitals to be reimbursed by Medicare or
Medicaid?
Answer: Accurate documentation according to diagnostic-related groups
(DRGs).
●● What reflects high-quality nursing documentation?
Answer: High-quality nursing documentation reflects the nursing
process.
●● What is the role of the medical record?
Answer: It serves as a major communication tool and is a legal
document.
●● Why are paper records being replaced by electronic health records
(EHRs)?
Answer: Paper records are fragile and susceptible to damage.
●● What should a nurse do when charting in a paper medical record?
Answer: Use black ink unless the facility allows a different color.
,●● Which document provides a longitudinal record of health?
Answer: Electronic health record (EHR).
●● What is a true statement about electronic health records?
Answer: They improve the overall patient's health status.
●● How can a nurse protect personal health information in EHRs?
Answer: The nurse should never share their password with anyone, even
a trusted colleague.
●● What should nursing documentation include?
Answer: Facts and subjective data from the patient.
●● What is the nursing process that guides documentation?
Answer: Assessment, diagnosis, planning, implementation, and
evaluation.
●● What do the documentation methods PIE, APIE, SOAP, and SOAPIE
have in common?
Answer: They are examples of problem-oriented charting.
●● What type of charting records only abnormal or significant data?
,Answer: Charting by exception (CBE).
●● What document should a nurse compare provider orders with before
administering medications?
Answer: Medication administration record (MAR).
●● What is the best source for a nurse to obtain a patient's history and
medications taken at home?
Answer: Admission summary.
●● What is a key fact about paper nursing notes?
Answer: A medical record is the most reliable source of information in a
legal action.
●● What identifies the person charting in electronic documentation?
Answer: Log-on access to the electronic record.
●● What action should a nurse take to correct an error in paper charting?
Answer: Draw a single line through the error and write 'error' above or
after the entry, along with the nurse's initials.
●● What action must be taken when a verbal or phone order is necessary
in an emergency?
, Answer: The order must be taken by an RN or LPN, repeated verbatim
to confirm accuracy, and documented as a written order.
●● What is the importance of hand-off reporting in nursing?
Answer: Hand-off reporting provides accurate, timely information to
ensure patient safety and can lead to collaborative problem solving.
●● What should a nurse do after a patient falls while attempting to climb
out of bed?
Answer: Complete an incident report as a risk management document.
●● What components of the patient's medical record should the nurse
document?
Answer: Nursing assessment, the care plan, and interventions.
●● Which abbreviations are considered unacceptable by The Joint
Commission?
Answer: QD, Qod, and IU.
●● What are the benefits of using standardized language in nursing
documentation?
Answer: It provides consistency, facilitates comparison of nursing
practice, promotes evidence-based quality care, and represents nursing
practice worldwide.
QUESTIONS AND COMPLETE RESPONSE
GUIDE
●● What is necessary for hospitals to be reimbursed by Medicare or
Medicaid?
Answer: Accurate documentation according to diagnostic-related groups
(DRGs).
●● What reflects high-quality nursing documentation?
Answer: High-quality nursing documentation reflects the nursing
process.
●● What is the role of the medical record?
Answer: It serves as a major communication tool and is a legal
document.
●● Why are paper records being replaced by electronic health records
(EHRs)?
Answer: Paper records are fragile and susceptible to damage.
●● What should a nurse do when charting in a paper medical record?
Answer: Use black ink unless the facility allows a different color.
,●● Which document provides a longitudinal record of health?
Answer: Electronic health record (EHR).
●● What is a true statement about electronic health records?
Answer: They improve the overall patient's health status.
●● How can a nurse protect personal health information in EHRs?
Answer: The nurse should never share their password with anyone, even
a trusted colleague.
●● What should nursing documentation include?
Answer: Facts and subjective data from the patient.
●● What is the nursing process that guides documentation?
Answer: Assessment, diagnosis, planning, implementation, and
evaluation.
●● What do the documentation methods PIE, APIE, SOAP, and SOAPIE
have in common?
Answer: They are examples of problem-oriented charting.
●● What type of charting records only abnormal or significant data?
,Answer: Charting by exception (CBE).
●● What document should a nurse compare provider orders with before
administering medications?
Answer: Medication administration record (MAR).
●● What is the best source for a nurse to obtain a patient's history and
medications taken at home?
Answer: Admission summary.
●● What is a key fact about paper nursing notes?
Answer: A medical record is the most reliable source of information in a
legal action.
●● What identifies the person charting in electronic documentation?
Answer: Log-on access to the electronic record.
●● What action should a nurse take to correct an error in paper charting?
Answer: Draw a single line through the error and write 'error' above or
after the entry, along with the nurse's initials.
●● What action must be taken when a verbal or phone order is necessary
in an emergency?
, Answer: The order must be taken by an RN or LPN, repeated verbatim
to confirm accuracy, and documented as a written order.
●● What is the importance of hand-off reporting in nursing?
Answer: Hand-off reporting provides accurate, timely information to
ensure patient safety and can lead to collaborative problem solving.
●● What should a nurse do after a patient falls while attempting to climb
out of bed?
Answer: Complete an incident report as a risk management document.
●● What components of the patient's medical record should the nurse
document?
Answer: Nursing assessment, the care plan, and interventions.
●● Which abbreviations are considered unacceptable by The Joint
Commission?
Answer: QD, Qod, and IU.
●● What are the benefits of using standardized language in nursing
documentation?
Answer: It provides consistency, facilitates comparison of nursing
practice, promotes evidence-based quality care, and represents nursing
practice worldwide.
