Chapter 26: Documentation and Informatics Test Bank
A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the
nurse preceptor to intervene?
a. The student nurse reviews the patient's medical record.
b. The student nurse reads the patient's plan of care.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient. - (correct Answer) - c. The
student nurse shares patient information with a friend.
A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which
action did the nurse complete? The nurse completed a
a. Report.
b. Record.
c. Consultation.
d. Referral. - (correct Answer) - a. Report.
Which situation best indicates that the nurse has a good understanding regarding auditing and
monitoring of patients' health records?
a. The nurse determines the degree to which standards of care are met by reviewing patients' health
records.
b. The nurse realizes that care not documented in patients' health records still qualifies as care provided.
c. The nurse knows that reimbursement is based on the diagnosis-related groups documented in
patients' records.
, d. The nurse compares data in patients' records to determine whether a new treatment had better
outcomes than the standard treatment. - (correct Answer) - a. The nurse determines the degree to which
standards of care are met by reviewing patients' health records.
After providing care, a nurse charts in the patient's record. Which entry should the nurse document?
a. Appears restless when sitting in the chair
b. Drank adequate amounts of water
c. Apparently is asleep with eyes closed
d. Skin pale and cool - (correct Answer) - d. Skin pale and cool
A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?
a. "Patient seems to be in pain and states, 'I feel uncomfortable.'"
b. Status unchanged, doing well
c. Left abdominal incision 1 inch in length without redness, drainage, or edema
d. Patient is hard to care for and refuses all treatments and medications. Family present. - (correct
Answer) - c. Left abdominal incision 1 inch in length without redness, drainage, or edema
A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to
intervene?
a. The new nurse uses a black ink pen to chart.
b. The new nurse charts consecutively on every other line.
c. The new nurse ends each entry with signature and title.
d. The new nurse keeps the password secure. - (correct Answer) - b. The new nurse charts consecutively
A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the
nurse preceptor to intervene?
a. The student nurse reviews the patient's medical record.
b. The student nurse reads the patient's plan of care.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient. - (correct Answer) - c. The
student nurse shares patient information with a friend.
A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which
action did the nurse complete? The nurse completed a
a. Report.
b. Record.
c. Consultation.
d. Referral. - (correct Answer) - a. Report.
Which situation best indicates that the nurse has a good understanding regarding auditing and
monitoring of patients' health records?
a. The nurse determines the degree to which standards of care are met by reviewing patients' health
records.
b. The nurse realizes that care not documented in patients' health records still qualifies as care provided.
c. The nurse knows that reimbursement is based on the diagnosis-related groups documented in
patients' records.
, d. The nurse compares data in patients' records to determine whether a new treatment had better
outcomes than the standard treatment. - (correct Answer) - a. The nurse determines the degree to which
standards of care are met by reviewing patients' health records.
After providing care, a nurse charts in the patient's record. Which entry should the nurse document?
a. Appears restless when sitting in the chair
b. Drank adequate amounts of water
c. Apparently is asleep with eyes closed
d. Skin pale and cool - (correct Answer) - d. Skin pale and cool
A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?
a. "Patient seems to be in pain and states, 'I feel uncomfortable.'"
b. Status unchanged, doing well
c. Left abdominal incision 1 inch in length without redness, drainage, or edema
d. Patient is hard to care for and refuses all treatments and medications. Family present. - (correct
Answer) - c. Left abdominal incision 1 inch in length without redness, drainage, or edema
A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to
intervene?
a. The new nurse uses a black ink pen to chart.
b. The new nurse charts consecutively on every other line.
c. The new nurse ends each entry with signature and title.
d. The new nurse keeps the password secure. - (correct Answer) - b. The new nurse charts consecutively
