EVOLVE DOCUMENTATION QUESTIONS WITH 100%
RATED ANSWERS 2025/2026 LATEST UPDATE/GET A+
When the nurse needs to notify a patient's guardian about the patient's health status,
where does the nurse access the information to contact the guardian? - Admission
sheet
A patient was shifted from the intensive care unit to the cardiac unit. What kinds of
reports are used to communicate between the two units? - Transfer reports
You are supervising a beginning nursing student who is documenting patient care.
Which actions require you to intervene? - The nursing student documented medication
given by another nursing student
What is an appropriate way for the nurse to dispose of printed patient information? -
Place in a secure canister marked for shredding
When updating a patient's chart, the nurse erroneously documents a wrong medication.
Upon realizing the mistake, what does the nurse do? - Strike with a single line, tag it as
an error, put initials, and document the correct medication.
A manager who is reviewing the nurses' notes in a patient's medical record finds the
following entry, "The patient is difficult to care for and refuses suggestions for improving
appetite." Which directions does the manager give to the staff nurse who entered the
note? - Enter only objective and factual information about the patient
Which charting entries are most accurate? - Patient walked 50 feet and back down
hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular
following exercise.
Communication among the members of a healthcare team is essential to providing
quality care to patients. Which are the modes for exchanging information among the
members of the healthcare team? Select all that apply. - Written reports
Oral communication
You are reviewing Health Insurance Portability and Accountability Act (HIPAA)
regulations with your patient during the admission process. The patient states, "I've
heard a lot about these HIPAA regulations in the news lately. How will they affect my
care?" Which option is the best response? - HIPAA provides you with greater control
over your personal healthcare information
On the nursing unit, you are able to access a patient's medical record and review the
education that other nurses provided to the patient during an initial hospitalization and
three subsequent clinic visits. This type of feature is most common in what type of
record system? - Electronic health record
, The nurse understands that patient records are legal documents and should be
accurate. What precautions should the nurse take when documenting? Select all that
apply. - Record all facts.
Record all written entries legibly and in black ink.
Begin each entry with date and time and end with signature and title.
The nurse faxes a patient's medical record to an unknown number. Which law is the
nurse violating? - The Health Insurance Portability and Accountability Act (HIPAA)
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? - The new nurse gives a newly ordered medication
before entering the order in the patient's medical record.
A nurse manager is educating the nursing staff on the importance of security with the
implementation of the electronic health record (EHR) on the unit. What points does the
manager emphasize? Select all that apply. - Do not share passwords with anyone.
Do not leave the patient's medical record open unattended on a computer screen.
Do not log in with someone else's user access.
The nurse is caring for a patient who has undergone abdominal surgery. The patient
informs the nurse of discomfort in the abdomen and is unable to turn to the left side.
The nurse finds that the patient has a temperature of 100.2° F, a respiratory rate of 28
breaths/minute, and a heart rate of 98 beats/minute. Which data should the nurse chart
under the O in SOAP charting? Select all that apply. - Temperature 100.2° F.
Respiratory rate 28 breaths/minute.
Heart rate 98 beats/minute
The nurse is giving information to a group of caregivers about electronic health records
(EHRs). What information about the EHR should the nurse offer them? Select all that
apply. - The EHR integrates all pertinent patient information into one record.
The EHR performs checks to support regulatory requirements.
The EHR provides the means to compare ongoing clinical data with baseline
information.
The nurse is recording specific demographic information about a patient in a hospital.
Which section of the traditional source record does the nurse use to record this
information? - Admission sheet
A patient is diagnosed with acute renal failure due to diabetes. Following treatment, the
patient recovers. The patient is being discharged to home on insulin. The nurse is
preparing a discharge summary for the patient. What information should the nurse
provide in the discharge summary? Select all that apply. - The contact information of the
healthcare provider.
The step-by-step instructions for self-administration of insulin.
The signs and symptoms that have to be reported to the healthcare provider.
RATED ANSWERS 2025/2026 LATEST UPDATE/GET A+
When the nurse needs to notify a patient's guardian about the patient's health status,
where does the nurse access the information to contact the guardian? - Admission
sheet
A patient was shifted from the intensive care unit to the cardiac unit. What kinds of
reports are used to communicate between the two units? - Transfer reports
You are supervising a beginning nursing student who is documenting patient care.
Which actions require you to intervene? - The nursing student documented medication
given by another nursing student
What is an appropriate way for the nurse to dispose of printed patient information? -
Place in a secure canister marked for shredding
When updating a patient's chart, the nurse erroneously documents a wrong medication.
Upon realizing the mistake, what does the nurse do? - Strike with a single line, tag it as
an error, put initials, and document the correct medication.
A manager who is reviewing the nurses' notes in a patient's medical record finds the
following entry, "The patient is difficult to care for and refuses suggestions for improving
appetite." Which directions does the manager give to the staff nurse who entered the
note? - Enter only objective and factual information about the patient
Which charting entries are most accurate? - Patient walked 50 feet and back down
hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular
following exercise.
Communication among the members of a healthcare team is essential to providing
quality care to patients. Which are the modes for exchanging information among the
members of the healthcare team? Select all that apply. - Written reports
Oral communication
You are reviewing Health Insurance Portability and Accountability Act (HIPAA)
regulations with your patient during the admission process. The patient states, "I've
heard a lot about these HIPAA regulations in the news lately. How will they affect my
care?" Which option is the best response? - HIPAA provides you with greater control
over your personal healthcare information
On the nursing unit, you are able to access a patient's medical record and review the
education that other nurses provided to the patient during an initial hospitalization and
three subsequent clinic visits. This type of feature is most common in what type of
record system? - Electronic health record
, The nurse understands that patient records are legal documents and should be
accurate. What precautions should the nurse take when documenting? Select all that
apply. - Record all facts.
Record all written entries legibly and in black ink.
Begin each entry with date and time and end with signature and title.
The nurse faxes a patient's medical record to an unknown number. Which law is the
nurse violating? - The Health Insurance Portability and Accountability Act (HIPAA)
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? - The new nurse gives a newly ordered medication
before entering the order in the patient's medical record.
A nurse manager is educating the nursing staff on the importance of security with the
implementation of the electronic health record (EHR) on the unit. What points does the
manager emphasize? Select all that apply. - Do not share passwords with anyone.
Do not leave the patient's medical record open unattended on a computer screen.
Do not log in with someone else's user access.
The nurse is caring for a patient who has undergone abdominal surgery. The patient
informs the nurse of discomfort in the abdomen and is unable to turn to the left side.
The nurse finds that the patient has a temperature of 100.2° F, a respiratory rate of 28
breaths/minute, and a heart rate of 98 beats/minute. Which data should the nurse chart
under the O in SOAP charting? Select all that apply. - Temperature 100.2° F.
Respiratory rate 28 breaths/minute.
Heart rate 98 beats/minute
The nurse is giving information to a group of caregivers about electronic health records
(EHRs). What information about the EHR should the nurse offer them? Select all that
apply. - The EHR integrates all pertinent patient information into one record.
The EHR performs checks to support regulatory requirements.
The EHR provides the means to compare ongoing clinical data with baseline
information.
The nurse is recording specific demographic information about a patient in a hospital.
Which section of the traditional source record does the nurse use to record this
information? - Admission sheet
A patient is diagnosed with acute renal failure due to diabetes. Following treatment, the
patient recovers. The patient is being discharged to home on insulin. The nurse is
preparing a discharge summary for the patient. What information should the nurse
provide in the discharge summary? Select all that apply. - The contact information of the
healthcare provider.
The step-by-step instructions for self-administration of insulin.
The signs and symptoms that have to be reported to the healthcare provider.
