NUR 104 MIDTERM EXAM EXCELSIOR COLLEGE
2025/2026 WITH ALL 180 QUESTIONS AND
CORRECT ANSWERS GRADED A/ NURSING NUR
104 EXAM LATEST VERSION 1 ANSWERS (BRAND
NEW!!)
A nurse begins the shift caring for a patient who has just returned from the recovery room after
surgery. It is most important to document: - CORRECT ANSWER-an initial assessment of the patient
and a plan based on the needs of the patient as assessed at the beginning of the shift.
A nurse enters a notation in a patient's chart but then discovers that the notation was made in the
wrong chart. The nurse correctly: - CORRECT ANSWER-draws a single line through the notation so
that it is still readable and writes "mistaken entry," his signature, and the date and time.
A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor
about this indicates that the: - CORRECT ANSWER-nurse has violated the confidentiality of the
patient by discussing personal information about the patient with his neighbor.
A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to
have the medical chart to take, because it is her personal property. An appropriate response would
be: - CORRECT ANSWER-"You are entitled to the information in your chart, but the chart is the
property of the hospital. I will see about having a copy made for you."
A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by
disruption of skin surface has the following nursing documentation: "Incision clean, dry, intact. No
pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing.
Verbalizes understanding of wound care and ability to manage at home. Wound healing without
complication." This documentation is: - CORRECT ANSWER-evidence of the use of the nursing
process.
A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says
to the nurse, "I don't want to have you draw any more blood for those useless tests." When the
nurse fails to convince the patient to have the blood drawn, the most appropriate documentation
would be: - CORRECT ANSWER-Refuses to have blood drawn; says tests are 'useless.' Doctor
notified."
,A student nurse is assigned to a clinical unit on which one of the patients is a nationally known
celebrity. The student reads the chart to find out why the celebrity is being treated. The student who
is not the assigned caregiver is: - CORRECT ANSWER-violating the confidentiality of the patient's
record.
Advantages of source-oriented or narrative charting include all of the following except that it: -
CORRECT ANSWER-encourages documentation of normal and abnormal findings.
If an agency is using computer-assisted charting, the nurse is responsible for: - CORRECT ANSWER-
guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves
the terminal.
In an agency that uses specific protocols (Standard Procedures) and charting by exception, an
advantage compared with using traditional (narrative or problem-oriented) charting is that charting
by exception: - CORRECT ANSWER-highlights abnormal data and patient trends.
The method of computer-assisted charting: (Select all that apply.) - CORRECT ANSWER-improves
communication between departments., speeds reimbursement for services., allows electronic
records to be retrieved more quickly., allows entries to be made at point of care.
The nurse understands that a face sheet contains information pertaining to: - CORRECT ANSWER-
patient data, including patient's name, address, phone number, insurance company, and admitting
diagnosis.
The nurse uses the flow sheet in patient care documentation primarily - CORRECT ANSWER-to track
routine assessments, treatments, and frequently given care.
The nurse with a patient who complains of severe pain documents every 15 minutes about the steps
taken to try to relieve the pain (without success). The nurse also documents the time and content of
two calls made to the patient's physician requesting that the physician examine the patient for
unexpected complications. This documentation by the nurse is likely to: - CORRECT ANSWER-justify
insurance reimbursement for an extended duration of hospitalization for the patient.
When the nurse charts in narrative or source-oriented format about the patient's condition and the
nursing care provided, it is appropriate for him to record: - CORRECT ANSWER-"To x-ray by
wheelchair @ 10:30 AM IV infusing in left arm."
, Which examples of documentation would be most informative to transcribe to the patient's medical
record? - CORRECT ANSWER-Patient consumed two slices of bread and a cup of coffee at breakfast."
Which nursing assessment is an example of brevity and clarity while meeting legal guidelines? -
CORRECT ANSWER-"4 cm reddened area over sacrum. Skin intact, warm, and dry."
The order in which the nursing process is approached is: - CORRECT ANSWER-assessment, nursing
diagnosis, planning, implementation, evaluation.
The major goal of the admission interview (usually performed by the RN) is to: - CORRECT ANSWER-
identify the patient's major complaints.
If a patient has several nursing diagnoses, the nurse will first: - CORRECT ANSWER-prioritize the
nursing problems according to Maslow's hierarchy of needs.
A nursing diagnosis identifies: (Select all that apply.) - CORRECT ANSWER-patient's response to
illness., related signs and symptoms., causative factors., potential risk for health problems.
A nursing diagnosis consists of: - CORRECT ANSWER-diagnostic labels formulated by the North
American Nursing Diagnosis Association-International (NANDA-I).
A nursing care plan consists of: - CORRECT ANSWER-nursing orders for individualized interventions
to assist the patient to meet expected outcomes.
A nurse will arrive at a nursing diagnosis through the nursing process step of: - CORRECT ANSWER-
assessment.
Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select
all that apply.) - CORRECT ANSWER-determination of potential health problems., clustering of
related assessments into a concept map
The planning stage of writing a care plan consists of deciding: - CORRECT ANSWER-What is realistic
for the patients condition
The participants of the planning stage of the nursing process during which the health goals are
defined include the: - CORRECT ANSWER-health team, the patient, and the patient's family.
2025/2026 WITH ALL 180 QUESTIONS AND
CORRECT ANSWERS GRADED A/ NURSING NUR
104 EXAM LATEST VERSION 1 ANSWERS (BRAND
NEW!!)
A nurse begins the shift caring for a patient who has just returned from the recovery room after
surgery. It is most important to document: - CORRECT ANSWER-an initial assessment of the patient
and a plan based on the needs of the patient as assessed at the beginning of the shift.
A nurse enters a notation in a patient's chart but then discovers that the notation was made in the
wrong chart. The nurse correctly: - CORRECT ANSWER-draws a single line through the notation so
that it is still readable and writes "mistaken entry," his signature, and the date and time.
A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor
about this indicates that the: - CORRECT ANSWER-nurse has violated the confidentiality of the
patient by discussing personal information about the patient with his neighbor.
A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to
have the medical chart to take, because it is her personal property. An appropriate response would
be: - CORRECT ANSWER-"You are entitled to the information in your chart, but the chart is the
property of the hospital. I will see about having a copy made for you."
A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by
disruption of skin surface has the following nursing documentation: "Incision clean, dry, intact. No
pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing.
Verbalizes understanding of wound care and ability to manage at home. Wound healing without
complication." This documentation is: - CORRECT ANSWER-evidence of the use of the nursing
process.
A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says
to the nurse, "I don't want to have you draw any more blood for those useless tests." When the
nurse fails to convince the patient to have the blood drawn, the most appropriate documentation
would be: - CORRECT ANSWER-Refuses to have blood drawn; says tests are 'useless.' Doctor
notified."
,A student nurse is assigned to a clinical unit on which one of the patients is a nationally known
celebrity. The student reads the chart to find out why the celebrity is being treated. The student who
is not the assigned caregiver is: - CORRECT ANSWER-violating the confidentiality of the patient's
record.
Advantages of source-oriented or narrative charting include all of the following except that it: -
CORRECT ANSWER-encourages documentation of normal and abnormal findings.
If an agency is using computer-assisted charting, the nurse is responsible for: - CORRECT ANSWER-
guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves
the terminal.
In an agency that uses specific protocols (Standard Procedures) and charting by exception, an
advantage compared with using traditional (narrative or problem-oriented) charting is that charting
by exception: - CORRECT ANSWER-highlights abnormal data and patient trends.
The method of computer-assisted charting: (Select all that apply.) - CORRECT ANSWER-improves
communication between departments., speeds reimbursement for services., allows electronic
records to be retrieved more quickly., allows entries to be made at point of care.
The nurse understands that a face sheet contains information pertaining to: - CORRECT ANSWER-
patient data, including patient's name, address, phone number, insurance company, and admitting
diagnosis.
The nurse uses the flow sheet in patient care documentation primarily - CORRECT ANSWER-to track
routine assessments, treatments, and frequently given care.
The nurse with a patient who complains of severe pain documents every 15 minutes about the steps
taken to try to relieve the pain (without success). The nurse also documents the time and content of
two calls made to the patient's physician requesting that the physician examine the patient for
unexpected complications. This documentation by the nurse is likely to: - CORRECT ANSWER-justify
insurance reimbursement for an extended duration of hospitalization for the patient.
When the nurse charts in narrative or source-oriented format about the patient's condition and the
nursing care provided, it is appropriate for him to record: - CORRECT ANSWER-"To x-ray by
wheelchair @ 10:30 AM IV infusing in left arm."
, Which examples of documentation would be most informative to transcribe to the patient's medical
record? - CORRECT ANSWER-Patient consumed two slices of bread and a cup of coffee at breakfast."
Which nursing assessment is an example of brevity and clarity while meeting legal guidelines? -
CORRECT ANSWER-"4 cm reddened area over sacrum. Skin intact, warm, and dry."
The order in which the nursing process is approached is: - CORRECT ANSWER-assessment, nursing
diagnosis, planning, implementation, evaluation.
The major goal of the admission interview (usually performed by the RN) is to: - CORRECT ANSWER-
identify the patient's major complaints.
If a patient has several nursing diagnoses, the nurse will first: - CORRECT ANSWER-prioritize the
nursing problems according to Maslow's hierarchy of needs.
A nursing diagnosis identifies: (Select all that apply.) - CORRECT ANSWER-patient's response to
illness., related signs and symptoms., causative factors., potential risk for health problems.
A nursing diagnosis consists of: - CORRECT ANSWER-diagnostic labels formulated by the North
American Nursing Diagnosis Association-International (NANDA-I).
A nursing care plan consists of: - CORRECT ANSWER-nursing orders for individualized interventions
to assist the patient to meet expected outcomes.
A nurse will arrive at a nursing diagnosis through the nursing process step of: - CORRECT ANSWER-
assessment.
Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select
all that apply.) - CORRECT ANSWER-determination of potential health problems., clustering of
related assessments into a concept map
The planning stage of writing a care plan consists of deciding: - CORRECT ANSWER-What is realistic
for the patients condition
The participants of the planning stage of the nursing process during which the health goals are
defined include the: - CORRECT ANSWER-health team, the patient, and the patient's family.
