CHAPTER 26 DOCUMENTATION REVIEW QUESTIONS WITH 100% RATED ANSWERS 2025/2026 LATEST UPDATE/GET A+

A patient asks for a copy of her medical record. The best response by the nurse is to: 1) State that only her family may read the record. 2) Indicate that she has the right to read her record. 3) Tell her that she is not allowed to read her record. 4) Explain that only health care workers have access to her record. - 2) Indicate that she has the right to read her record. Which of the following charting entries is most accurate? 1) Patient walked up and down hallway with assistance, tolerated well. 2) Patient up, out of bed, walked down hallway and back to room, tolerated well. 3) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. 4) Patient walked 50 feet and back down hallway with assistance from nuse; HR 88 and regular before exercise, 94 and regular following exercise. - 4) Patient walked 50 feet and back down hallway with assistance from nuse; HR 88 and regular before exercise, 94 and regular following exercise. Match the correct entry with the appropriate SOAP (Subjective-Objective-Assessment- Plan) category. 1) Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. 2) "The pain increases every time I try to turn on my left side." 3) Acute pain related to tissue injury from surgical incision. 4) Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. - 2, 4, 3, 1. On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? 1) Information technology. 2) Electronic health record. 3) Personal health information. 4) Administrative information system. - 2) Electronic health record. You are giving a hand-off report to another nurse who eill be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply) 1) The patient's name, age, and admitting diagnosis. 2) Allergies to food and medications. 3) Your evaluation that the patient is "needy". 4) How much the patient ate for breakfast. 5) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol. - 1, 2, 5. You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: 1) Documented medication given by another nursing student. 2) Included the date and time of all entries in the chart. 3) Stood with his back against the wall while documenting on the computer. 4) Signed all documents electronically. - 1) Documented medication given by another nursing student.