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

Using the SOAP format, which represents the appropriate O statement? 1) Reposition the patient on the right side. Encourage the patient to use the patient- controlled analgesia (PCA) device. 2) The patient states, "The pain increases every time I try to turn on my left side." 3) Acute pain is related to tissue injury from a surgical incision. 4) Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. - Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. Using the SOAP format, which represents the appropriate A statement? 1) Reposition the patient on the right side. Encourage the patient to use the patient- controlled analgesia (PCA) device. 2) The patient states, "The pain increases every time I try to turn on my left side." 3) Acute pain is related to tissue injury from a surgical incision. 4) Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. - Acute pain is related to tissue injury from a surgical incision. The nurse is caring for a patient who has returned to the floor after a knee replacement in the morning. Which statements written in the nurse record are accurate? (Select all that apply.) 1) Oxycodeine 2 tabs given for pain. 2) IV restarted, infusing without difficulty. 3) Pain seems to be reduced. 4) Heart rate: 75/minute, urine voided 300 mL, pain rated as 7 on a scale of 0 to10. 5) Temp: 102 degrees Fahrenheit at 5:00 pm, paracetamol 500 mg at 5:00 pm, temperature 99 degrees Fahrenheit at 6:30 pm - -Heart rate: 75/minute, urine voided 300 mL, pain rated as 7 on a scale of 0 to10. -Temp: 102 degrees Fahrenheit at 5:00 pm, paracetamol 500 mg at 5:00 pm, temperature 99 degrees Fahrenheit at 6:30 pm The nurse caring for a patient in a home care setting needs detailed documentation. What are the purposes of the documentation? (Select all that apply.) 1) The documentation justifies reimbursement. 2) The documentation provides information regarding quality of work. 3) The documentation provides data for acuity records. 4) The documentation serves as a reference document for other professionals involved in the care. 5) The documentation provides the health care team with detailed knowledge for coordination of care. - -The documentation justifies reimbursement. -The documentation provides information regarding quality of work. -The documentation serves as a reference document for other professionals involved in the care. -The documentation provides the health care team with detailed knowledge for coordination of care. Acuity records - used to assess the hours of care and the duration of time the staff needed to take care of a patient A nurse manager is reviewing a hand-off report prepared by a new nurse. What statements require the manager to advise the nurse on the correct techniques of documentation and informatics? (Select all that apply.) 1) The patient is stable and is adhering to the drug regimen. 2) The patient is extremely uncooperative and grumbles all the time. 3) The patient is stable and has no reports of pain. 4) The patient is feeling healthy and refreshed. 5) The patient, who is 65 years old, is stable with no pain. - -The patient is extremely uncooperative and grumbles all the time. -The patient is feeling healthy and refreshed. -The patient, who is 65 years old, is stable with no pain. A nurse is teaching a group of student nurses about legal guidelines for the effective recording of a patient's data on a handwritten paper document. Which statement by a student nurse needs correction? 1) "I should avoid using generalized, empty phrases." 2) "I should put a line through errors made while recording." 3) "I should record all written entries legibly and in black ink." 4) "I should leave spaces with unknown information blank." - "I should leave spaces with unknown information blank." A hospital unit maintains documentation in the form of a problem-oriented medical record (POMR). The nurse notices that a patient reports symptoms of acid reflux. On further assessment, the nurse finds that the patient has fully recovered from typhoid. Where and how does the nurse update the record? (Select all that apply.) 1) Add the new problem to the problem list of the patient. 2) Highlight typhoid and add the date of recovery. 3) Highlight reflux and add the date of the occurrence of the sign. 4) Remove the old progress note and add a new one with updates. 5) Add a new admission assessment along with the existing records. - -Add the new problem to the problem list of the patient. -Highlight typhoid and add the date of recovery. The nurse is recording specific demographic info about a patient in a hospital. Which section of the traditional source record does the nurse use to record this info? Nurses' notes Admission sheet Graphic sheet and flow sheet Nurse's admission assessment - Admission sheet Demographic information includes: - -legal name -identification number -gender -age -birth date -marital status -occupation -health insurance -nearest relative -religious preference -name of attending physician -date and time of admission What info is included on the admission sheet section? - Demographic information Nurses' notes include: - -information about the assessment -nursing diagnosis -planning -implementation -evaluation of care The nurse's admission assessment section includes what? - a summary of the patient's nursing history and physical exam A new graduate nurse is providing a telephone report to a patient's healthcare provider and accepting telephone orders from the provider. Which actions require the new nurse's preceptor to intervene? 1) The new nurse uses SBAR as a format when providing the report. 2) The new nurse gives a newly ordered meds before entering the order in the patient's medical record. 3) The new nurse reads the orders back to the healthcare provider after receiving them and verifies their accuracy. 4) The new nurse asks the preceptor to listen in on the phone conversation. - The new nurse gives a newly ordered meds before entering the order in the patient's medical record. SBAR - Situation Background Assessment Recommendation