NURS 550 Documentation Exam With Questions And
Accurate Solutions 2024-2025
A charge nurse is talking to staff at a provider's office about features of electronic
documentation. Which of the following features should the charge nurse plan to
address? Select all that apply.
Decreases medical errors
Improve interdisciplinary team members' listening skills
Not as convenient as paper-based charting
Makes client medical history more accessible
Improves coding procedures accuracy Answer Decreases medical errors
Makes client medical history more accessible
Improves coding procedures accuracy
A charge nurse is providing education about SOAP documentation to a group of newly
licensed nurses. Which of the following chart entries should the nurse provide as an
example of objective data?
-The client states, "I have had abdominal pain for the past 3 days."
-The client reports he drinks about 1,500 mL of water a day
-Rebound tenderness present in RLQ of abdomen
-Referral to a registered dietician was advised for the client Recommendation Rebound
tenderness present in RLQ of abdomen
The charge nurse is reviewing charts with a newly licensed nurse. Which of the
following does the nurse recognize as being part of a health record?
, -Immunization records
-Client record of healthcare payments
-Family members' medical record
-Agency policy - Answer Immunization records
A nurse is taking an admission history from a client who states, "I don't think it's a good
idea that this facility uses an electronic system to document information." Which of the
following would be an appropriate response by the nurse as a positive aspect of an
electronic documentation system?
The system alerts providers about possible actions that could harm the client
An electronic system prevents breaches of confidentiality of client information
It is possible for providers to document information about the client in the electronic
record during periods of system downtime
-System encryption eliminates the use of security firewalls. Response The system alerts
providers of possible actions that may result in patient harm
A newly licensed nurse is being evaluated for her knowledge concerning telephone
prescriptions by a staff nurse. Which of the following responses by the newly licensed
nurse indicates an acknowledgment of understanding?
- "A telephone prescription is obtained when a provider is making routine rounds in
another part of the facility"
-"I can take a telephone prescription if a provider is directing a code for an
unresponsive client."
"If a client requires an over-the-counter medication for relief of nausea, it is okay to
accept a telephone prescription."
-"It is acceptable to take a telephone prescription if a client needs pain control for a
terminal condition." Response "I can take a telephone prescription if a provider is
directing a code for an unresponsive client."
Accurate Solutions 2024-2025
A charge nurse is talking to staff at a provider's office about features of electronic
documentation. Which of the following features should the charge nurse plan to
address? Select all that apply.
Decreases medical errors
Improve interdisciplinary team members' listening skills
Not as convenient as paper-based charting
Makes client medical history more accessible
Improves coding procedures accuracy Answer Decreases medical errors
Makes client medical history more accessible
Improves coding procedures accuracy
A charge nurse is providing education about SOAP documentation to a group of newly
licensed nurses. Which of the following chart entries should the nurse provide as an
example of objective data?
-The client states, "I have had abdominal pain for the past 3 days."
-The client reports he drinks about 1,500 mL of water a day
-Rebound tenderness present in RLQ of abdomen
-Referral to a registered dietician was advised for the client Recommendation Rebound
tenderness present in RLQ of abdomen
The charge nurse is reviewing charts with a newly licensed nurse. Which of the
following does the nurse recognize as being part of a health record?
, -Immunization records
-Client record of healthcare payments
-Family members' medical record
-Agency policy - Answer Immunization records
A nurse is taking an admission history from a client who states, "I don't think it's a good
idea that this facility uses an electronic system to document information." Which of the
following would be an appropriate response by the nurse as a positive aspect of an
electronic documentation system?
The system alerts providers about possible actions that could harm the client
An electronic system prevents breaches of confidentiality of client information
It is possible for providers to document information about the client in the electronic
record during periods of system downtime
-System encryption eliminates the use of security firewalls. Response The system alerts
providers of possible actions that may result in patient harm
A newly licensed nurse is being evaluated for her knowledge concerning telephone
prescriptions by a staff nurse. Which of the following responses by the newly licensed
nurse indicates an acknowledgment of understanding?
- "A telephone prescription is obtained when a provider is making routine rounds in
another part of the facility"
-"I can take a telephone prescription if a provider is directing a code for an
unresponsive client."
"If a client requires an over-the-counter medication for relief of nausea, it is okay to
accept a telephone prescription."
-"It is acceptable to take a telephone prescription if a client needs pain control for a
terminal condition." Response "I can take a telephone prescription if a provider is
directing a code for an unresponsive client."
