Nursing Documentation Practice
Questions with Complete Solutions
What is the primary purpose of using a standardized documentation format in nursing?
A) To increase the length of patient records
B) To ensure consistency and clarity in patient documentation
✔✔ C) To allow for easier billing
D) To comply with regulatory agencies
Which of the following is an example of subjective data in nursing documentation?
✔✔ A) Patient reports feeling nauseous
B) Patient’s blood pressure reading
C) Patient’s temperature measured at 98.6°F
D) Patient’s wound appearance
When documenting a patient's response to a new medication, what should the nurse include?
A) The nurse’s personal opinion on the medication
✔✔ B) Any changes in symptoms or side effects noted
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,C) The history of the patient’s previous medications
D) The cost of the medication
What is an important consideration when documenting in an electronic health record (EHR)?
A) The design of the computer workstation
✔✔ B) Ensuring that documentation is entered in real-time to maintain accuracy
C) The color of the text used in the documentation
D) The physical location of the computer
If a nurse realizes they have made an error in the documentation, what is the appropriate action?
✔✔ A) Draw a single line through the error, write "error," and correct the mistake
B) Delete the erroneous entry and write the correct information
C) Ignore the error if it’s minor
D) Inform the patient of the error and leave it uncorrected
What should be included in documentation when a patient is discharged?
A) The cost of the patient’s treatment
✔✔ B) Discharge instructions, follow-up care, and the patient's condition at discharge
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, C) The nurse’s personal comments about the patient
D) Details of the patient's previous hospital visits
Why is it important to document patient education provided by the nurse?
A) To meet the hospital’s quota for patient education
✔✔ B) To provide a record that the patient received and understood the information
C) To increase the length of the patient’s medical record
D) To ensure the nurse is reimbursed for the education provided
What should a nurse do if a patient’s family member provides important information about the
patient’s condition?
A) Document the information but do not verify it
✔✔ B) Document the information, note the family member’s name, and verify with the patient
or medical records
C) Ignore the information if it’s not from the patient directly
D) Only document the family member's contact information
Which of the following best describes the concept of "timeliness" in nursing documentation?
A) Completing documentation at the end of the nurse’s shift
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Questions with Complete Solutions
What is the primary purpose of using a standardized documentation format in nursing?
A) To increase the length of patient records
B) To ensure consistency and clarity in patient documentation
✔✔ C) To allow for easier billing
D) To comply with regulatory agencies
Which of the following is an example of subjective data in nursing documentation?
✔✔ A) Patient reports feeling nauseous
B) Patient’s blood pressure reading
C) Patient’s temperature measured at 98.6°F
D) Patient’s wound appearance
When documenting a patient's response to a new medication, what should the nurse include?
A) The nurse’s personal opinion on the medication
✔✔ B) Any changes in symptoms or side effects noted
1
,C) The history of the patient’s previous medications
D) The cost of the medication
What is an important consideration when documenting in an electronic health record (EHR)?
A) The design of the computer workstation
✔✔ B) Ensuring that documentation is entered in real-time to maintain accuracy
C) The color of the text used in the documentation
D) The physical location of the computer
If a nurse realizes they have made an error in the documentation, what is the appropriate action?
✔✔ A) Draw a single line through the error, write "error," and correct the mistake
B) Delete the erroneous entry and write the correct information
C) Ignore the error if it’s minor
D) Inform the patient of the error and leave it uncorrected
What should be included in documentation when a patient is discharged?
A) The cost of the patient’s treatment
✔✔ B) Discharge instructions, follow-up care, and the patient's condition at discharge
2
, C) The nurse’s personal comments about the patient
D) Details of the patient's previous hospital visits
Why is it important to document patient education provided by the nurse?
A) To meet the hospital’s quota for patient education
✔✔ B) To provide a record that the patient received and understood the information
C) To increase the length of the patient’s medical record
D) To ensure the nurse is reimbursed for the education provided
What should a nurse do if a patient’s family member provides important information about the
patient’s condition?
A) Document the information but do not verify it
✔✔ B) Document the information, note the family member’s name, and verify with the patient
or medical records
C) Ignore the information if it’s not from the patient directly
D) Only document the family member's contact information
Which of the following best describes the concept of "timeliness" in nursing documentation?
A) Completing documentation at the end of the nurse’s shift
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