Chapter 26 Documentation NUR 225
Practice Questions and 100% Correct
Answers
A manager is reviewing the nursing documentation entered by a staff nurse in a
patient's electronic medical record and finds the following entry, "Patient is difficult to
care for, refuses suggestion for improving appetite." Which of the following statements
is most appropriate for the manager to make to the staff nurse who entered this
information?
A. "Avoid rushing when documenting an entry in the medical record."
B. "Use correction fluid to remove the entry."
C. "Draw a single line through the statement and initial it."
D. Enter only objective and factual information about a patient in the medical record.
✅D. Enter only objective and factual information about a patient in the medical record.
Nurses should enter only objective and factual information about patients. Opinions
have no place in the medical record. Because the information has already been entered
and is not incorrect, it should be left on the record. Never use correction fluid in a written
medical record.
A preceptor observes a new graduate nurse discussing changes in a patient's condition
with a physician over the phone. The new graduate nurse accepts telephone orders for
a new medication and for some laboratory tests from the physician at the end of the
conversation. During the conversation the new graduate writes the orders down on a
piece of paper to enter them into the electronic medical record when a computer
terminal is available. At this hospital new medication orders entered into the electronic
medical record can be viewed immediately by hospital pharmacists, and hospital policy
states that all new medications must be reviewed by a pharmacist before being
administered to patients. Which of the following actions requires the preceptor to
intervene? The new nurse:
A. Reads the orders back to the health care provider to verify accuracy of transcribing
the orders after receiving them over the phone.
B. Documents ✅C. Gives a newly ordered medication before entering the order in the
patient's medical record.
When provider orders for new medication(s) are entered into an electronic medical
record, the new orders are available to pharmacists using the same electronic system
within the hospital. To improve patient safety, many hospitals have a policy that new
medications are not to be administered (unless in an emergency) until a pharmacist
reviews the new order(s) and verifies that there are no documented allergies to the
medications, the ordered dose(s) are appropriate, and there are no potential medication
interactions with medications already ordered for a patient. Nurses enter orders into the
, computer or write them on the order sheet as they are being given to allow the read-
back process to occur.
As the nurse enters a patient's room, the nurse notices that the patient is anxious. The
patient quickly states, "I don't know what's going on; I can't get an explanation from my
doctor about my test results. I want something done about this." Which of the following
is the most appropriate way for the nurse to document this observation of the patient?
A. "The patient has a defiant attitude and is demanding test results."
B. "The patient appears to be upset with the nurse because he wants his test results
immediately."
C. "The patient is demanding and is complaining about the doctor."
D. "The patient stated feelings of frustration from the lack of information received
regarding test results." ✅D. "The patient stated feelings of frustration from the lack of
information received regarding test results."
This is a nonjudgmental statement regarding the nurse's observations about the patient.
Documenting that the patient has a defiant attitude or is demanding is judgmental, and
information in the medical record should be factual and nonjudgmental. Noting that the
patient appeared upset with the nurse needs to be more specific; it does not provide
enough information regarding the reason for the patient's concern.
The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA)
regulations with the patient during the admission process. The patient states, "I'm not
familiar with these HIPAA regulations. How will they affect my care?" Which of the
following is the best response?
A. HIPAA allows all hospital staff access to your medical record.
B. HIPAA limits the information that is documented in your medical record.
C. HIPAA provides you with greater protection of your personal health information.
D. HIPAA enables health care institutions to release all of your personal information to
improve continuity of care. ✅C. HIPAA provides you with greater protection of your
personal health information.
HIPAA provides patients with control over who receives and accesses their medical
records. It does not allow uncontrolled access to the medical records. HIPAA also does
not dictate what must be documented in the patient's medical record.
A patient states, "I would like to see what is written in my medical record." What is the
nurse's best response?
A. "Only your family can read your medical record."
B. "You have the right to read your record."
C. "Patients are not allowed to read their records."
D. "Only health care workers have access to patient records." ✅B. "You have the right
to read your record."
Patients have the right to read their medical records, but the nurse should always know
the facility policy regarding personal access to medical records because some require a
Practice Questions and 100% Correct
Answers
A manager is reviewing the nursing documentation entered by a staff nurse in a
patient's electronic medical record and finds the following entry, "Patient is difficult to
care for, refuses suggestion for improving appetite." Which of the following statements
is most appropriate for the manager to make to the staff nurse who entered this
information?
A. "Avoid rushing when documenting an entry in the medical record."
B. "Use correction fluid to remove the entry."
C. "Draw a single line through the statement and initial it."
D. Enter only objective and factual information about a patient in the medical record.
✅D. Enter only objective and factual information about a patient in the medical record.
Nurses should enter only objective and factual information about patients. Opinions
have no place in the medical record. Because the information has already been entered
and is not incorrect, it should be left on the record. Never use correction fluid in a written
medical record.
A preceptor observes a new graduate nurse discussing changes in a patient's condition
with a physician over the phone. The new graduate nurse accepts telephone orders for
a new medication and for some laboratory tests from the physician at the end of the
conversation. During the conversation the new graduate writes the orders down on a
piece of paper to enter them into the electronic medical record when a computer
terminal is available. At this hospital new medication orders entered into the electronic
medical record can be viewed immediately by hospital pharmacists, and hospital policy
states that all new medications must be reviewed by a pharmacist before being
administered to patients. Which of the following actions requires the preceptor to
intervene? The new nurse:
A. Reads the orders back to the health care provider to verify accuracy of transcribing
the orders after receiving them over the phone.
B. Documents ✅C. Gives a newly ordered medication before entering the order in the
patient's medical record.
When provider orders for new medication(s) are entered into an electronic medical
record, the new orders are available to pharmacists using the same electronic system
within the hospital. To improve patient safety, many hospitals have a policy that new
medications are not to be administered (unless in an emergency) until a pharmacist
reviews the new order(s) and verifies that there are no documented allergies to the
medications, the ordered dose(s) are appropriate, and there are no potential medication
interactions with medications already ordered for a patient. Nurses enter orders into the
, computer or write them on the order sheet as they are being given to allow the read-
back process to occur.
As the nurse enters a patient's room, the nurse notices that the patient is anxious. The
patient quickly states, "I don't know what's going on; I can't get an explanation from my
doctor about my test results. I want something done about this." Which of the following
is the most appropriate way for the nurse to document this observation of the patient?
A. "The patient has a defiant attitude and is demanding test results."
B. "The patient appears to be upset with the nurse because he wants his test results
immediately."
C. "The patient is demanding and is complaining about the doctor."
D. "The patient stated feelings of frustration from the lack of information received
regarding test results." ✅D. "The patient stated feelings of frustration from the lack of
information received regarding test results."
This is a nonjudgmental statement regarding the nurse's observations about the patient.
Documenting that the patient has a defiant attitude or is demanding is judgmental, and
information in the medical record should be factual and nonjudgmental. Noting that the
patient appeared upset with the nurse needs to be more specific; it does not provide
enough information regarding the reason for the patient's concern.
The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA)
regulations with the patient during the admission process. The patient states, "I'm not
familiar with these HIPAA regulations. How will they affect my care?" Which of the
following is the best response?
A. HIPAA allows all hospital staff access to your medical record.
B. HIPAA limits the information that is documented in your medical record.
C. HIPAA provides you with greater protection of your personal health information.
D. HIPAA enables health care institutions to release all of your personal information to
improve continuity of care. ✅C. HIPAA provides you with greater protection of your
personal health information.
HIPAA provides patients with control over who receives and accesses their medical
records. It does not allow uncontrolled access to the medical records. HIPAA also does
not dictate what must be documented in the patient's medical record.
A patient states, "I would like to see what is written in my medical record." What is the
nurse's best response?
A. "Only your family can read your medical record."
B. "You have the right to read your record."
C. "Patients are not allowed to read their records."
D. "Only health care workers have access to patient records." ✅B. "You have the right
to read your record."
Patients have the right to read their medical records, but the nurse should always know
the facility policy regarding personal access to medical records because some require a
