NUR 155 Exam 1: 50 Questions & Answers: 100 % Verified: Latest
Updated A+ Score Guide Solution
Foundations of Nursing Practice: Clinical Essentials and Assessment
1. How should a nurse approach bathing a patient who has dementia?
A. Complete the bath as quickly as possible to prevent distress.
B. Coerce the patient to ensure hygiene standards are strictly maintained.
C. Focus on the person rather than the task, and stop if the patient becomes
distressed.
D. Perform the bath at the exact same time every day regardless of patient
preference.
Correct Answer: C
Rationale: When bathing a patient with dementia, the nurse must focus on the
person rather than the task, use persuasion instead of coercion, and stop the bath
immediately if the patient becomes distressed
.
2. Which component of a Source-Oriented Record is used to document body
temperature, pulse rate, respiratory rate, blood pressure, daily weight, and O2
saturation?
A. Initial nursing assessment
B. Daily care record
C. Graphic record
D. Special flow sheets
Correct Answer: C
,Rationale: The graphic record in a Source-Oriented Record is designed to display
measurements such as body temperature, pulse rate, respiratory rate, blood
pressure, daily weight, fluid intake and output, and O2 saturation
.
3. What are the four basic components of a Problem-Oriented Medical Record
(POMR)?
A. SBAR, S1/S2 heart sounds, SOAP notes, and flow sheets
B. Assessing, Diagnosing, Planning, and Evaluating (ADPE)
C. Database, Problem list, Plan of care, and Progress notes
D. Direct transmission, Indirect transmission, Airborne transmission, and Host
Correct Answer: C
Rationale: The POMR structure consists of four basic components: the database,
problem list, plan of care, and progress notes
.
4. Which documentation system relies on the rule that only abnormal or
significant findings or exceptions to norms are recorded?
A. Source-Oriented Record
B. Problem-Oriented Medical Record
C. Focus Charting
D. Charting by Exception
Correct Answer: D
Rationale: Charting by Exception (CBE) is a documentation system in which only
abnormal or significant findings or exceptions to norms are recorded
5. In Focus Charting, what does the progress notes acronym "DAR" stand for?
A. Diagnosis, Assessment, Recommendation
, B. Data, Action, Response
C. Documentation, Activity, Reassessment
D. Database, Action plan, Evaluation
Correct Answer: B
Rationale: Focus Charting uses three columns for recording progress notes
organized into (D) data, (A) action, and (R) response
6. A nurse is calling a healthcare provider using the SBAR format. Under which
section should the nurse state the client's admission diagnosis, date of admission,
permanent medical history, and treatment to date?
A. S (Situation)
B. B (Background)
C. A (Assessment)
D. R (Recommendation)
Correct Answer: B
Rationale: The Background (B) phase of SBAR requires stating the client's
admission diagnosis, date of admission, permanent medical history, treatment
summary, and code status
.
7. What form of communication promotes client safety by minimizing
miscommunication, using honest, direct, and appropriate statements that rely on
"I" rather than "you"?
A. Passive communication
B. Submissive communication
C. Aggressive communication
Updated A+ Score Guide Solution
Foundations of Nursing Practice: Clinical Essentials and Assessment
1. How should a nurse approach bathing a patient who has dementia?
A. Complete the bath as quickly as possible to prevent distress.
B. Coerce the patient to ensure hygiene standards are strictly maintained.
C. Focus on the person rather than the task, and stop if the patient becomes
distressed.
D. Perform the bath at the exact same time every day regardless of patient
preference.
Correct Answer: C
Rationale: When bathing a patient with dementia, the nurse must focus on the
person rather than the task, use persuasion instead of coercion, and stop the bath
immediately if the patient becomes distressed
.
2. Which component of a Source-Oriented Record is used to document body
temperature, pulse rate, respiratory rate, blood pressure, daily weight, and O2
saturation?
A. Initial nursing assessment
B. Daily care record
C. Graphic record
D. Special flow sheets
Correct Answer: C
,Rationale: The graphic record in a Source-Oriented Record is designed to display
measurements such as body temperature, pulse rate, respiratory rate, blood
pressure, daily weight, fluid intake and output, and O2 saturation
.
3. What are the four basic components of a Problem-Oriented Medical Record
(POMR)?
A. SBAR, S1/S2 heart sounds, SOAP notes, and flow sheets
B. Assessing, Diagnosing, Planning, and Evaluating (ADPE)
C. Database, Problem list, Plan of care, and Progress notes
D. Direct transmission, Indirect transmission, Airborne transmission, and Host
Correct Answer: C
Rationale: The POMR structure consists of four basic components: the database,
problem list, plan of care, and progress notes
.
4. Which documentation system relies on the rule that only abnormal or
significant findings or exceptions to norms are recorded?
A. Source-Oriented Record
B. Problem-Oriented Medical Record
C. Focus Charting
D. Charting by Exception
Correct Answer: D
Rationale: Charting by Exception (CBE) is a documentation system in which only
abnormal or significant findings or exceptions to norms are recorded
5. In Focus Charting, what does the progress notes acronym "DAR" stand for?
A. Diagnosis, Assessment, Recommendation
, B. Data, Action, Response
C. Documentation, Activity, Reassessment
D. Database, Action plan, Evaluation
Correct Answer: B
Rationale: Focus Charting uses three columns for recording progress notes
organized into (D) data, (A) action, and (R) response
6. A nurse is calling a healthcare provider using the SBAR format. Under which
section should the nurse state the client's admission diagnosis, date of admission,
permanent medical history, and treatment to date?
A. S (Situation)
B. B (Background)
C. A (Assessment)
D. R (Recommendation)
Correct Answer: B
Rationale: The Background (B) phase of SBAR requires stating the client's
admission diagnosis, date of admission, permanent medical history, treatment
summary, and code status
.
7. What form of communication promotes client safety by minimizing
miscommunication, using honest, direct, and appropriate statements that rely on
"I" rather than "you"?
A. Passive communication
B. Submissive communication
C. Aggressive communication
