NUR 112 Exam 1 2026 | Practice Questions &
Verified Answers | Comprehensive Nursing Exam
Review
Elements of Documentation (Guidelines) - Precise Answer ✔✔-
accessible
- accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing- specific manner.
Who should document? - Precise Answer ✔✔Whoever is responsible for
the nurses care should chart but others can chart in as well. Everyone
should document!!!
Why should you document without error? - Precise Answer ✔✔Poor
documentation can be presumed as medical negligence. "CYA".
Make sure you're documenting without error/ i.e. Don't document the
wrong BP. Can possibly affect medication dosage.
Errors make nurses look less credible. Which can affect credibility.
What is informatics? - Precise Answer ✔✔computer and software
systems (may include pager system any type of tech)
Should you skip lines if you're charting? - Precise Answer ✔✔No!
,Approved abreviations - Precise Answer ✔✔A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
s- without
ss- one-half
t.i.d.- three times a day
What is HIPAA - Precise Answer ✔✔Health Insurance Portability and
Accountability Act
Potential Breaches in Patient Confidentiality - Precise Answer
✔✔Displaying information on a public screen
-Sending confidential e-mail messages via public networks
-Sharing printers among units with differing functions
-Discarding copies of patient information in trash cans
-Holding conversations that can be overheard
-Faxing confidential information to unauthorized persons
, -Sending confidential messages overheard on pagers
Hypothetically, if a patient had yellow skin, was not wearing pants, was
smiling, and its stomach is sticking out, and the patient also states, "I'm
rumbly in my tummly." How would you chart this? - Precise Answer
✔✔Patient has generalized jaundice. Ambulating in room. Patient is not
wearing pants. Protruding abdomen. The patient is smiling. No signs of
distress. Patient states I'm rumbly in my tummy. Patient "I'm hungry".
Patient's have the right to: - Precise Answer ✔✔-See and copy their
health record
-Update their health record
-Get a list of disclosures
-Request a restriction on certain uses or disclosures
-Choose how to receive health information
what can patient's NOT do to their paperwork? - Precise Answer
✔✔patient's cannot revise info
Documentation - Precise Answer ✔✔written or electronic legal record
kept by nurses for assessing and planning
What is the nursing process? - Precise Answer ✔✔Assessment
Diagnosis
Planning
Implementation
Evaluation
content must be factual - meaning what can you see? - Precise Answer
✔✔examples: Shortness of breath, cardiac arrest, patient is in use of
oxygen with 2 Liters, etc.
Factual charting example vs. not - Precise Answer ✔✔Factual: patient is
lying in bed at 15 degrees with eyes closed
Verified Answers | Comprehensive Nursing Exam
Review
Elements of Documentation (Guidelines) - Precise Answer ✔✔-
accessible
- accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing- specific manner.
Who should document? - Precise Answer ✔✔Whoever is responsible for
the nurses care should chart but others can chart in as well. Everyone
should document!!!
Why should you document without error? - Precise Answer ✔✔Poor
documentation can be presumed as medical negligence. "CYA".
Make sure you're documenting without error/ i.e. Don't document the
wrong BP. Can possibly affect medication dosage.
Errors make nurses look less credible. Which can affect credibility.
What is informatics? - Precise Answer ✔✔computer and software
systems (may include pager system any type of tech)
Should you skip lines if you're charting? - Precise Answer ✔✔No!
,Approved abreviations - Precise Answer ✔✔A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
s- without
ss- one-half
t.i.d.- three times a day
What is HIPAA - Precise Answer ✔✔Health Insurance Portability and
Accountability Act
Potential Breaches in Patient Confidentiality - Precise Answer
✔✔Displaying information on a public screen
-Sending confidential e-mail messages via public networks
-Sharing printers among units with differing functions
-Discarding copies of patient information in trash cans
-Holding conversations that can be overheard
-Faxing confidential information to unauthorized persons
, -Sending confidential messages overheard on pagers
Hypothetically, if a patient had yellow skin, was not wearing pants, was
smiling, and its stomach is sticking out, and the patient also states, "I'm
rumbly in my tummly." How would you chart this? - Precise Answer
✔✔Patient has generalized jaundice. Ambulating in room. Patient is not
wearing pants. Protruding abdomen. The patient is smiling. No signs of
distress. Patient states I'm rumbly in my tummy. Patient "I'm hungry".
Patient's have the right to: - Precise Answer ✔✔-See and copy their
health record
-Update their health record
-Get a list of disclosures
-Request a restriction on certain uses or disclosures
-Choose how to receive health information
what can patient's NOT do to their paperwork? - Precise Answer
✔✔patient's cannot revise info
Documentation - Precise Answer ✔✔written or electronic legal record
kept by nurses for assessing and planning
What is the nursing process? - Precise Answer ✔✔Assessment
Diagnosis
Planning
Implementation
Evaluation
content must be factual - meaning what can you see? - Precise Answer
✔✔examples: Shortness of breath, cardiac arrest, patient is in use of
oxygen with 2 Liters, etc.
Factual charting example vs. not - Precise Answer ✔✔Factual: patient is
lying in bed at 15 degrees with eyes closed
