NSE 211
NSE 211 Midterm Preparation Exam Study
Questions with Correct Answers Updated 2026
Name the different methods used in record keeping.
Narrative notes, SOAP, PIE, DAR
Define A Narrative Note
The use of a story-like format to document information.
Define SOAP notes
Subjective data (verbalizations of the patient), Objective data (that which is
measured and observed), Assessment (diagnosis based on the data), and Plan (what
the caregiver plans to do). In some institutions, an "I" and an "E" are added (i.e.,
SOAPIE), for Intervention and Evaluation. The logic of the SOAPIE note format is
similar to that of the nursing process. The nurse collects data about a patient's
problems, draws conclusions, develops a plan of care, and then evaluates the
outcome(s). Each SOAP note is numbered and titled according to the problem on
the list that it addressed
Define a " PIE" Note
(Problem—Intervention—Evaluation) simplifies documentation by unifying the
care plan and progress notes. PIE notes differ from SOAP notes in that the
narrative does not include assessment information. A nurse's daily assessment data
appear on flow sheets, preventing duplication of data. The narrative note includes
the problem, the intervention, and the evaluation. The PIE notes are numbered or
labeled according to the patient's problems. Resolved problems are dropped from
daily documentation after the nurse's review. Continuing problems are documented
daily
Define DAR note
Data (both subjective and objective), Action or nursing intervention, and Response
of the patient (i.e., evaluation of effectiveness). A DAR note addresses patient
concerns: a sign or symptom, condition, nursing diagnosis, behavior, significant
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event, or change in a patient's condition. Documentation in this format also follows
the nursing process. This format enables nurses to broaden their thinking to include
any patient concerns, not just problem areas. Focus charting incorporates all
aspects of the nursing process, highlights a patient's concerns, and can be
integrated into any clinical setting.
What type of nursing note is this?
- "I'm worried about the surgery. Last time I had a lot of pain when I got out of
bed."
- Asking multiple questions about how postoperative pain will be addressed.
- Anxiety related to perceived threat of postoperative pain as evidenced by
statement of prior experience with uncontrolled postoperative pain.
- Explain routine postoperative analgesic plan of care. Encourage to inform nursing
staff as soon as possible if pain is not relieved. - Explain rationale for early
postoperative ambulation and demonstrate TCDB exercises. Provide teaching
booklet on postoperative nursing care.
SOAP-
It follows this format of subjectivity (patients concern), objectivity (what's being
measured/ what is seen), assessment (what you assessed due to the findings) , and
plan (what you will enact)
What is a change of shift report? Name some examples.
(TOA, SBAR, I-SBAR-R, and I PASS)
At the end of each shift, nurses report information about their assigned patients to
the nurses working on the next shift
What is a Transfer of Accountability (TOA) process?
The outgoing night nurse and the incoming day nurse engage in a verbal report and
complete a patient safety checklist at the bedside.
- Significant facts about patients are reviewed (e.g., condition of wounds, episodes
of chest pain) to provide a baseline for comparison during the next shift. Data
about patients need to be objective, current, and concise.
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,NSE 211
Define the Situation-background-assessment-recommendation (SBAR) technique
or identification-situation-background-assessment-recommendation-read back (I-
SBAR-R) technique.
Situational briefing system that fosters a culture of patient safety. This technique
can be incorporated into a variety of ways of reporting (e.g., a nurse's report to a
physician about a critically ill patient, change-of-shift reports about individual
patients) and can be adapted for use with or by other health care providers
What is I-PASS?
Illness severity, patient information, action list, situational awareness, and
contingency plans, and synthesis by receiver
What is a wound?
a break in the continuity of body structure caused by violence, trauma, or surgery
to tissues body
What are the types of wound healing?
primary intention
secondary intention
tertiary intention
What is primary intention?
Use of suture or other wound closures to approximate the edges of an incision or
clean laceration and healing is primarily through collagen synthesis- produces a
"Hair-line" Scar
Primary Intention: Inflammatory Phase
3-5 days
o Edges of the incisions are aligned, well approximated (sutured or stapled in
place)
o The incision area fills with the blood of cut blood vessels causing blood clot
formation and platelet releasing growth factors to begin healing
o Matrix forms for WBC migration and causes an acute inflammatory reaction, The
area of injury is composed of fibrin clots, erythrocytes, neutrophils (dead and
dying), and other debris.
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o Macrophages ingest and digest cellular debris, fibrin fragments, and red blood
cells. Extracellular enzymes from macrophages and neutrophils help digest fibrin
o As the wound debris is removed, the fibrin clot becomes a framework for future
capillary growth and migration of epithelial cells
Primary Intention: Granulation Phase
(5days- 3 weeks)
o The components of granulation tissue include proliferating fibroblasts;
proliferating capillary sprouts (angioblasts); various types of WBCs; exudate; and
loose, semifluid, ground substance.
o Fibroblasts are immature connective tissue cells that migrate into the healing site
and secrete collagen. In time, the collagen is organized and restructured to
strengthen the healing site.
o At this stage, it is termed fibrous or scar tissue.
o Pink and vascular wound, Numerous red granules (young budding capillaries)
are present.
o the wound is friable, at risk for dehiscence, and resistant to infection.
o Surface epithelium at the wound edges begins to regenerate. In a few days, a thin
layer of epithelium migrates across the wound surface in a one-cell thick layer until
it contacts cells spreading from the opposite direction. The epithelium thickens and
begins to mature, and the wound now closely resembles the adjacent skin.
o In a superficial wound, re-epithelialization may take
Primary Intention: Remodeling Phase
(7 days after the injury, in which scar contraction occurs, overlaps with the
granulation phase.)
o continues for several months or years, during which time collagen fibres are
further organized, and the remodelling process occurs.
o Fibroblasts disappear as the scar becomes stronger.
NSE 211
NSE 211 Midterm Preparation Exam Study
Questions with Correct Answers Updated 2026
Name the different methods used in record keeping.
Narrative notes, SOAP, PIE, DAR
Define A Narrative Note
The use of a story-like format to document information.
Define SOAP notes
Subjective data (verbalizations of the patient), Objective data (that which is
measured and observed), Assessment (diagnosis based on the data), and Plan (what
the caregiver plans to do). In some institutions, an "I" and an "E" are added (i.e.,
SOAPIE), for Intervention and Evaluation. The logic of the SOAPIE note format is
similar to that of the nursing process. The nurse collects data about a patient's
problems, draws conclusions, develops a plan of care, and then evaluates the
outcome(s). Each SOAP note is numbered and titled according to the problem on
the list that it addressed
Define a " PIE" Note
(Problem—Intervention—Evaluation) simplifies documentation by unifying the
care plan and progress notes. PIE notes differ from SOAP notes in that the
narrative does not include assessment information. A nurse's daily assessment data
appear on flow sheets, preventing duplication of data. The narrative note includes
the problem, the intervention, and the evaluation. The PIE notes are numbered or
labeled according to the patient's problems. Resolved problems are dropped from
daily documentation after the nurse's review. Continuing problems are documented
daily
Define DAR note
Data (both subjective and objective), Action or nursing intervention, and Response
of the patient (i.e., evaluation of effectiveness). A DAR note addresses patient
concerns: a sign or symptom, condition, nursing diagnosis, behavior, significant
NSE 211
,NSE 211
event, or change in a patient's condition. Documentation in this format also follows
the nursing process. This format enables nurses to broaden their thinking to include
any patient concerns, not just problem areas. Focus charting incorporates all
aspects of the nursing process, highlights a patient's concerns, and can be
integrated into any clinical setting.
What type of nursing note is this?
- "I'm worried about the surgery. Last time I had a lot of pain when I got out of
bed."
- Asking multiple questions about how postoperative pain will be addressed.
- Anxiety related to perceived threat of postoperative pain as evidenced by
statement of prior experience with uncontrolled postoperative pain.
- Explain routine postoperative analgesic plan of care. Encourage to inform nursing
staff as soon as possible if pain is not relieved. - Explain rationale for early
postoperative ambulation and demonstrate TCDB exercises. Provide teaching
booklet on postoperative nursing care.
SOAP-
It follows this format of subjectivity (patients concern), objectivity (what's being
measured/ what is seen), assessment (what you assessed due to the findings) , and
plan (what you will enact)
What is a change of shift report? Name some examples.
(TOA, SBAR, I-SBAR-R, and I PASS)
At the end of each shift, nurses report information about their assigned patients to
the nurses working on the next shift
What is a Transfer of Accountability (TOA) process?
The outgoing night nurse and the incoming day nurse engage in a verbal report and
complete a patient safety checklist at the bedside.
- Significant facts about patients are reviewed (e.g., condition of wounds, episodes
of chest pain) to provide a baseline for comparison during the next shift. Data
about patients need to be objective, current, and concise.
NSE 211
,NSE 211
Define the Situation-background-assessment-recommendation (SBAR) technique
or identification-situation-background-assessment-recommendation-read back (I-
SBAR-R) technique.
Situational briefing system that fosters a culture of patient safety. This technique
can be incorporated into a variety of ways of reporting (e.g., a nurse's report to a
physician about a critically ill patient, change-of-shift reports about individual
patients) and can be adapted for use with or by other health care providers
What is I-PASS?
Illness severity, patient information, action list, situational awareness, and
contingency plans, and synthesis by receiver
What is a wound?
a break in the continuity of body structure caused by violence, trauma, or surgery
to tissues body
What are the types of wound healing?
primary intention
secondary intention
tertiary intention
What is primary intention?
Use of suture or other wound closures to approximate the edges of an incision or
clean laceration and healing is primarily through collagen synthesis- produces a
"Hair-line" Scar
Primary Intention: Inflammatory Phase
3-5 days
o Edges of the incisions are aligned, well approximated (sutured or stapled in
place)
o The incision area fills with the blood of cut blood vessels causing blood clot
formation and platelet releasing growth factors to begin healing
o Matrix forms for WBC migration and causes an acute inflammatory reaction, The
area of injury is composed of fibrin clots, erythrocytes, neutrophils (dead and
dying), and other debris.
NSE 211
, NSE 211
o Macrophages ingest and digest cellular debris, fibrin fragments, and red blood
cells. Extracellular enzymes from macrophages and neutrophils help digest fibrin
o As the wound debris is removed, the fibrin clot becomes a framework for future
capillary growth and migration of epithelial cells
Primary Intention: Granulation Phase
(5days- 3 weeks)
o The components of granulation tissue include proliferating fibroblasts;
proliferating capillary sprouts (angioblasts); various types of WBCs; exudate; and
loose, semifluid, ground substance.
o Fibroblasts are immature connective tissue cells that migrate into the healing site
and secrete collagen. In time, the collagen is organized and restructured to
strengthen the healing site.
o At this stage, it is termed fibrous or scar tissue.
o Pink and vascular wound, Numerous red granules (young budding capillaries)
are present.
o the wound is friable, at risk for dehiscence, and resistant to infection.
o Surface epithelium at the wound edges begins to regenerate. In a few days, a thin
layer of epithelium migrates across the wound surface in a one-cell thick layer until
it contacts cells spreading from the opposite direction. The epithelium thickens and
begins to mature, and the wound now closely resembles the adjacent skin.
o In a superficial wound, re-epithelialization may take
Primary Intention: Remodeling Phase
(7 days after the injury, in which scar contraction occurs, overlaps with the
granulation phase.)
o continues for several months or years, during which time collagen fibres are
further organized, and the remodelling process occurs.
o Fibroblasts disappear as the scar becomes stronger.
NSE 211
