PN 108- TEST 1 STUDYGUIDE QUESTIONS AND CORRECT ANSWERS
Question:
1. Documentation is reflective of the nursing process and an integral part of which phase?
Answer:
Implementation phase.
Question:
2. The patients chart and medical record provides the following a concise, accurate and
permanent record of the following?
Answer:
Past & current medical & nursing problems. Plans for care Care given Patient responses to
previous
Question:
3. In order for healthcare organizations to be reimbursed, what is the nurse required to do in
order to show the institutions patient care?
Answer:
Proper charting.
Question:
4. Who is the legal owner of a medical record?
Answer:
Physician.
Question:
5. What type of documentation is a safety measure that aids in communicating with other
nurses during handoff report?
Answer:
ISBAR.
Question:
6. When a documentation error is made, what should you do?
Answer:
Draw a single line through the error & follow agency policy for identifying errors, then record note
correctly.
Question:
7. When documenting and you end in the middle of the line, what should be done to prevent
another person from inserting information?
Answer:
Draw a line horizontally through it and sign at the end.
Question:
, 8. When using the SOAPIER method of documentation, what does the "S'' stand for?
Answer:
Subjective information which provides what the patient states or feels; only the pamation.
Question:
9. What does DARE stand for in focus charting?
Answer:
Data, Action, Response & Evaluation, Education & patient teaching.
Question:
10. What is initially required by the nurse for Charting by exception?
Answer:
Complete physical assessment, Observations, Vital signs, Intravenous site(IV) & rate, and other
pertinent data.
Question:
11. What is required after initial assessments throughout the day?
Answer:
Additional treatments done, planned treatments withheld, changes in patient's condition, new
concerns.
Question:
12. Nursing care plans were developed by nurses for nurses and based on nursing
assessment. What do they include?
Answer:
Pertinent patient problems, goals, plans for care, specific actions for care implementation,
evaluation.
Question:
13. What type of paperwork is required to document ant event that is not consistent with
routine operation of a health care unit or routine care of a patient?
Answer:
Incident Report.
Question:
14. Convert 3:12am to military time.
Answer:
0312.
Question:
15. Convert 12:15pm to military time.
Answer:
1215.
Question:
1. Documentation is reflective of the nursing process and an integral part of which phase?
Answer:
Implementation phase.
Question:
2. The patients chart and medical record provides the following a concise, accurate and
permanent record of the following?
Answer:
Past & current medical & nursing problems. Plans for care Care given Patient responses to
previous
Question:
3. In order for healthcare organizations to be reimbursed, what is the nurse required to do in
order to show the institutions patient care?
Answer:
Proper charting.
Question:
4. Who is the legal owner of a medical record?
Answer:
Physician.
Question:
5. What type of documentation is a safety measure that aids in communicating with other
nurses during handoff report?
Answer:
ISBAR.
Question:
6. When a documentation error is made, what should you do?
Answer:
Draw a single line through the error & follow agency policy for identifying errors, then record note
correctly.
Question:
7. When documenting and you end in the middle of the line, what should be done to prevent
another person from inserting information?
Answer:
Draw a line horizontally through it and sign at the end.
Question:
, 8. When using the SOAPIER method of documentation, what does the "S'' stand for?
Answer:
Subjective information which provides what the patient states or feels; only the pamation.
Question:
9. What does DARE stand for in focus charting?
Answer:
Data, Action, Response & Evaluation, Education & patient teaching.
Question:
10. What is initially required by the nurse for Charting by exception?
Answer:
Complete physical assessment, Observations, Vital signs, Intravenous site(IV) & rate, and other
pertinent data.
Question:
11. What is required after initial assessments throughout the day?
Answer:
Additional treatments done, planned treatments withheld, changes in patient's condition, new
concerns.
Question:
12. Nursing care plans were developed by nurses for nurses and based on nursing
assessment. What do they include?
Answer:
Pertinent patient problems, goals, plans for care, specific actions for care implementation,
evaluation.
Question:
13. What type of paperwork is required to document ant event that is not consistent with
routine operation of a health care unit or routine care of a patient?
Answer:
Incident Report.
Question:
14. Convert 3:12am to military time.
Answer:
0312.
Question:
15. Convert 12:15pm to military time.
Answer:
1215.
