lOMoARcPSD|27916040
Test bank on MOSBY'S ESSENTIALS
FOR NURSING ASSISTANTS
WORKBOOK, 7TH EDITION
1.Which is not a purpose of the client care record?
a.To serve as a legal document.
b.To facilitate reimbursement
c.To serve as a contract with the client.
d.To assist with care planning.: c
2.Which is the primary purpose of client records?
a. Communication
b. Reimbursement
c. Legal protection
d. Performance improvement: a
3.Which note includes all elements of a SOAP note?
,a. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea.
Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart
rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an
antiemetic and reassess within 1 hour for effectiveness.
b. Client reports nausea, vomiting, and diarrhea x 3 days. Denies any sick contacts or
recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate
of 92 beats/min.
c. Client reports nausea and vomiting x 3 days. Vital signs stable. Most likely due to
gastroenteritis.
d. Client with nausea, vomiting, diarrhea, most likely secondary to gastroen- teritis.
Will give an antiemetic and reassess.: a
4.A nurse is documenting client care using the SOAP format. Place the statements
listed below in the order that the nurse would record them.
a. "I don't feel well. I've been urinating often, and it burns when I urinate."
b. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees
F. Indwelling urinary catheter removed 2 days ago.
c. Fever, possible urinary tract infection.
, lOMoARcPSD|27916040
d. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor
temperature.: 1. a
2.b
3.c
4.d
5.The charge nurse is reviewing SOAP format documentation with a newly hired nurse.
What information should the charge nurse discuss?
a. Subjective data should be included when documenting.
b. Objective data are what the client states about the problem
c.The plan includes interventions, evaluation, and response
d. Abnormal laboratory values are common items that are documented.: a
6.A nurse is following a clinical pathway that guides the care of a client after knee surgery
When the nurse observes the client vomiting, it creates a deviation from the clinica
pathway. What should the nurse identify this event as?
a. A never event
b. A variance
, c. An audit
d. A sentinel event: b
7.A nurse accidentally gives a double dose of blood pressure medication. After ensuring
the safety of the client, the nurse would record the error in which documents?
a. Client's record and occurrence report
b. Occurrence report and clinical pathway
c. Critical pathway and care plan
d. Care plan and client's record: a
8.Which statement by the nurse would indicate to the charge nurse that there is need for
further teaching on the purposes of medical records?
a. "The clients' medical records provide data for legal evidence."
b. "I can share the clients' medical records with the health care team."
c. "The clients' medical records are an obstruction to research and educa- tion."
d. "The clients' health records should be used to promote reimbursement from
insurance companies": c
9.The nurse documents that a client does not have pain prior to the admin- istration of
pain medication. The client, however, requested medication for
Test bank on MOSBY'S ESSENTIALS
FOR NURSING ASSISTANTS
WORKBOOK, 7TH EDITION
1.Which is not a purpose of the client care record?
a.To serve as a legal document.
b.To facilitate reimbursement
c.To serve as a contract with the client.
d.To assist with care planning.: c
2.Which is the primary purpose of client records?
a. Communication
b. Reimbursement
c. Legal protection
d. Performance improvement: a
3.Which note includes all elements of a SOAP note?
,a. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea.
Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart
rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an
antiemetic and reassess within 1 hour for effectiveness.
b. Client reports nausea, vomiting, and diarrhea x 3 days. Denies any sick contacts or
recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate
of 92 beats/min.
c. Client reports nausea and vomiting x 3 days. Vital signs stable. Most likely due to
gastroenteritis.
d. Client with nausea, vomiting, diarrhea, most likely secondary to gastroen- teritis.
Will give an antiemetic and reassess.: a
4.A nurse is documenting client care using the SOAP format. Place the statements
listed below in the order that the nurse would record them.
a. "I don't feel well. I've been urinating often, and it burns when I urinate."
b. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees
F. Indwelling urinary catheter removed 2 days ago.
c. Fever, possible urinary tract infection.
, lOMoARcPSD|27916040
d. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor
temperature.: 1. a
2.b
3.c
4.d
5.The charge nurse is reviewing SOAP format documentation with a newly hired nurse.
What information should the charge nurse discuss?
a. Subjective data should be included when documenting.
b. Objective data are what the client states about the problem
c.The plan includes interventions, evaluation, and response
d. Abnormal laboratory values are common items that are documented.: a
6.A nurse is following a clinical pathway that guides the care of a client after knee surgery
When the nurse observes the client vomiting, it creates a deviation from the clinica
pathway. What should the nurse identify this event as?
a. A never event
b. A variance
, c. An audit
d. A sentinel event: b
7.A nurse accidentally gives a double dose of blood pressure medication. After ensuring
the safety of the client, the nurse would record the error in which documents?
a. Client's record and occurrence report
b. Occurrence report and clinical pathway
c. Critical pathway and care plan
d. Care plan and client's record: a
8.Which statement by the nurse would indicate to the charge nurse that there is need for
further teaching on the purposes of medical records?
a. "The clients' medical records provide data for legal evidence."
b. "I can share the clients' medical records with the health care team."
c. "The clients' medical records are an obstruction to research and educa- tion."
d. "The clients' health records should be used to promote reimbursement from
insurance companies": c
9.The nurse documents that a client does not have pain prior to the admin- istration of
pain medication. The client, however, requested medication for
