NCLEX Questions_ Chapter 26:
Documentation and Informatics, Bowel
Elimination, Urinary Elimination
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_ANS: C When you are a student in a clinical setting,
confidentiality and compliance with the Health Insurance Portability and Accountability Act
(HIPAA) are part of professional practice. When a student nurse shares patient information
with a friend, confidentiality and HIPAA standards have been violated. You can review your
patients' medical records only to seek information needed to provide safe and effective
patient care. For example, when you are assigned to care for a patient, you need to review
the patient's medical record and plan of care. You do not share this information with
classmates and you do not access the medical records of other patients on the unit 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_ANS: A Reports are oral, written, or audiotaped exchanges of
information among caregivers. A patient's record or chart is a confidential, permanent legal
document consisting of information relevant to his or her health care. Consultations are
another form of discussion in which one professional caregiver gives formal advice about the
care of a patient to another caregiver. Nurses document referrals (arrangements for the
services of another care provider). 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_ANS: A The patient record is a valuable source of data
for all members of the health care team. Its purposes include communication, legal
documentation, financial billing, education, research, and auditing/monitoring. The
auditing/monitoring purpose involves nurses auditing records throughout the year to
determine the degree to which standards of care are met and to identify areas needing
improvement and staff development. The legal documentation purpose involves the concept
that even though nursing care may have been excellent, in a court of law, "care not
documented is care not provided." The financial billing or reimbursement purpose involves
diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care.
For research purposes, the researcher compares the patient's recorded findings to
determine whether the new method was more effective than the standard protocol.
Analysis of data from research contributes to evidence-based nursing practice and quality
health care 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_ANS: D A factual record contains descriptive, objective information about what a
nurse sees, hears, feels, and smells. An objective description is the result of direct
observation and measurement. For example, "B/P 80/50, patient diaphoretic, heart rate 102
and regular." Avoid vague terms such as appears, seems, or apparently because these words
,suggest that you are stating an opinion, do not accurately communicate facts, and do not
inform another caregiver of details regarding behaviors exhibited by the patient. Use of
exact measurements establishes accuracy. For example, a description such as "Intake, 360
mL of water" is more accurate than "Patient drank an adequate amount of fluid." 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_ANS: C Use of exact measurements establishes accuracy. Charting
that an abdominal wound is "5 cm in length without redness, drainage, or edema" is more
descriptive than "large wound healing well." Include objective data to support subjective
data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases
such as "status unchanged" or "had a good day." It is essential to avoid the use of
unnecessary words and irrelevant details or personal opinions. "Patient is hard to care for" is
a personal opinion and should be avoided. It is also a critical comment that can be used as
evidence for nonprofessional behavior or poor quality of care. Just chart, "Refuses all
treatments and medications." 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_ANS: B Chart consecutively, line by line (not every other line); if space is left, draw a
line horizontally through it, and sign your name at the end. Every other line should not be
left blank. Record all entries legibly and in black ink. End each entry with your signature and
title. For computer documentation, keep your password to yourself. Using black ink, ending
each entry with signature and title, and keeping the password secure are all appropriate
behaviors A nurse is charting on a patient's record. Which action is most accurate legally? a.
Charts legibly b. States the patient is belligerent c. Uses correction fluid to correct error d.
Writes entry for another nurse -correct answer_ANS: A Record all entries legibly. Do not
write personal opinions. Enter only objective and factual observations of patient's behavior;
quote all patient comments. For example, patient refuses to cough and deep breathe, saying,
"I don't care what you say, I will not do it." Do not erase, apply correction fluid, or scratch
out errors made while recording. Chart only for yourself A nurse wants to integrate all
pertinent patient information into one record, regardless of the number of times a patient
enters the health care system. Which term should the nurse use to describe this system? a.
Electronic medical record b. Electronic health record c. Electronic charting record d.
Electronic problem record -correct answer_ANS: B A unique feature of an electronic health
record (EHR) is its ability to integrate all pertinent patient information into one record,
regardless of the number of times a patient enters a health care system. Although the
electronic medical record (EMR) contains patient data gathered in a health care setting at a
specific time and place and is a part of the EHR, the two terms are frequently used
interchangeably. There are no such terms as electronic charting record or electronic
problem record A nurse has taught the patient how to use crutches. The patient went up
and down the stairs using crutches with no difficulties. Which information will the nurse use
for the "I" in PIE charting? a. Patient went up and down stairs b. Deficient knowledge
regarding crutches c. Demonstrated use of crutches d. Used crutches with no difficulties
-correct answer_ANS: C A second progress note method is the PIE format. The narrative note
includes P—Problem, I—Intervention, and E—Evaluation. The intervention is "Demonstrated
use of crutches." "Patient went up and down stairs" and "Used crutches with no difficulties"
are examples of the E. "Deficient knowledge regarding crutches" is the P. A nurse is using the
source record and wants to find the daily weights. Where should the nurse look? a. Database
b. Medical history and examination c. Progress notes d. Graphic sheet and flow sheet
, -correct answer_ANS: D In a source record, the patient's chart has a separate section for
each discipline (e.g., nursing, medicine, social work, respiratory therapy) in which to record
data. Graphic sheets and flow sheets are records of repeated observations and
measurements such as vital signs, daily weights, and intake and output. In the
problem-oriented medical record, the database section contains all available assessment
information pertaining to the patient (e.g., history and physical examination, the nurse's
admission history and ongoing assessment, the dietitian's assessment, laboratory reports,
radiologic test results). In the source record, the medical history and examination contain
results of the initial examination performed by the physician, including findings, family
history, confirmed diagnoses, and medical plan of care. In the source record, the progress
notes contain an ongoing record of the patient's progress and response to medical therapy
and a review of the disease process; it often is interdisciplinary and includes documentation
from health-related disciplines (e.g., health care providers, physical therapy, social work). A
nurse is a member of an interdisciplinary team that uses critical pathways. According to the
critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is
day 3, and the patient cannot sit in the chair. What should the nurse do? a. Focus charting
using the DAR format. b. Add this data to the problem list. c. Document the variance in the
patient's record. d. Report a positive variance in the next interdisciplinary team meeting.
-correct answer_ANS: C A variance occurs when the activities on the critical pathway are not
completed as predicted, or the patient does not meet expected outcomes. An example of a
variance is when a patient develops pulmonary complications after surgery, requiring
oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a
patient progresses more rapidly than expected (e.g., use of a Foley catheter may be
discontinued a day early). When a nurse is using the problem-oriented medical record, after
analyzing data, health care team members identify problems and make a single problem list.
A type of narrative format charting is focus charting. It involves the use of DAR notes, which
include D—Data (both subjective and objective), A—Action or nursing intervention, and
R—Response of the patient (i.e., evaluation of effectiveness). A nurse needs to begin
discharge planning for a patient admitted with pneumonia and a congested cough. When is
the best time the nurse should start discharge planning for this patient? a. Upon admission b.
Right before discharge c. After the congestion is treated d. When the primary care provider
writes the order -correct answer_ANS: A Ideally, discharge planning begins at admission.
Right before discharge is too late for discharge planning. After the congestion is treated is
also too late for discharge planning. Usually the primary care provider writes the order too
close to discharge, and nurses do not need an order to begin the teaching that will be
needed for discharge. By identifying discharge needs early, nursing and other health care
professionals can begin planning for home care, support services, and any equipment needs
at home A patient is being discharged home. Which information should the nurse include? a.
Acuity level b. Community resources c. Standardized care plan d. Kardex -correct
answer_ANS: B Discharge documentation includes medications, diet, community resources,
follow-up care, and whom to contact in case of an emergency or for questions. A patient's
acuity level, usually determined by a computer program, is based on the type and number of
nursing interventions (e.g., intravenous [IV] therapy, wound care, ambulation assistance)
required over a 24-hour period. Acuity level can be used for staffing and billing. Some
institutions use standardized care plans to make documentation more efficient. The plans,
based on the institution's standards of nursing practice, are preprinted, established
guidelines used to care for patients who have similar health problems. In some settings, a
Kardex, a portable "flip-over" file or notebook, is kept at the nurses' station. Most Kardex
forms have an activity and treatment section and a nursing care plan section, which organize
information for quick reference. A nurse developed the following discharge summary sheet.
Which critical information should be added? TOPIC DISCHARGE SUMMARY Medication Diet
Documentation and Informatics, Bowel
Elimination, Urinary Elimination
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_ANS: C When you are a student in a clinical setting,
confidentiality and compliance with the Health Insurance Portability and Accountability Act
(HIPAA) are part of professional practice. When a student nurse shares patient information
with a friend, confidentiality and HIPAA standards have been violated. You can review your
patients' medical records only to seek information needed to provide safe and effective
patient care. For example, when you are assigned to care for a patient, you need to review
the patient's medical record and plan of care. You do not share this information with
classmates and you do not access the medical records of other patients on the unit 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_ANS: A Reports are oral, written, or audiotaped exchanges of
information among caregivers. A patient's record or chart is a confidential, permanent legal
document consisting of information relevant to his or her health care. Consultations are
another form of discussion in which one professional caregiver gives formal advice about the
care of a patient to another caregiver. Nurses document referrals (arrangements for the
services of another care provider). 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_ANS: A The patient record is a valuable source of data
for all members of the health care team. Its purposes include communication, legal
documentation, financial billing, education, research, and auditing/monitoring. The
auditing/monitoring purpose involves nurses auditing records throughout the year to
determine the degree to which standards of care are met and to identify areas needing
improvement and staff development. The legal documentation purpose involves the concept
that even though nursing care may have been excellent, in a court of law, "care not
documented is care not provided." The financial billing or reimbursement purpose involves
diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care.
For research purposes, the researcher compares the patient's recorded findings to
determine whether the new method was more effective than the standard protocol.
Analysis of data from research contributes to evidence-based nursing practice and quality
health care 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_ANS: D A factual record contains descriptive, objective information about what a
nurse sees, hears, feels, and smells. An objective description is the result of direct
observation and measurement. For example, "B/P 80/50, patient diaphoretic, heart rate 102
and regular." Avoid vague terms such as appears, seems, or apparently because these words
,suggest that you are stating an opinion, do not accurately communicate facts, and do not
inform another caregiver of details regarding behaviors exhibited by the patient. Use of
exact measurements establishes accuracy. For example, a description such as "Intake, 360
mL of water" is more accurate than "Patient drank an adequate amount of fluid." 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_ANS: C Use of exact measurements establishes accuracy. Charting
that an abdominal wound is "5 cm in length without redness, drainage, or edema" is more
descriptive than "large wound healing well." Include objective data to support subjective
data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases
such as "status unchanged" or "had a good day." It is essential to avoid the use of
unnecessary words and irrelevant details or personal opinions. "Patient is hard to care for" is
a personal opinion and should be avoided. It is also a critical comment that can be used as
evidence for nonprofessional behavior or poor quality of care. Just chart, "Refuses all
treatments and medications." 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_ANS: B Chart consecutively, line by line (not every other line); if space is left, draw a
line horizontally through it, and sign your name at the end. Every other line should not be
left blank. Record all entries legibly and in black ink. End each entry with your signature and
title. For computer documentation, keep your password to yourself. Using black ink, ending
each entry with signature and title, and keeping the password secure are all appropriate
behaviors A nurse is charting on a patient's record. Which action is most accurate legally? a.
Charts legibly b. States the patient is belligerent c. Uses correction fluid to correct error d.
Writes entry for another nurse -correct answer_ANS: A Record all entries legibly. Do not
write personal opinions. Enter only objective and factual observations of patient's behavior;
quote all patient comments. For example, patient refuses to cough and deep breathe, saying,
"I don't care what you say, I will not do it." Do not erase, apply correction fluid, or scratch
out errors made while recording. Chart only for yourself A nurse wants to integrate all
pertinent patient information into one record, regardless of the number of times a patient
enters the health care system. Which term should the nurse use to describe this system? a.
Electronic medical record b. Electronic health record c. Electronic charting record d.
Electronic problem record -correct answer_ANS: B A unique feature of an electronic health
record (EHR) is its ability to integrate all pertinent patient information into one record,
regardless of the number of times a patient enters a health care system. Although the
electronic medical record (EMR) contains patient data gathered in a health care setting at a
specific time and place and is a part of the EHR, the two terms are frequently used
interchangeably. There are no such terms as electronic charting record or electronic
problem record A nurse has taught the patient how to use crutches. The patient went up
and down the stairs using crutches with no difficulties. Which information will the nurse use
for the "I" in PIE charting? a. Patient went up and down stairs b. Deficient knowledge
regarding crutches c. Demonstrated use of crutches d. Used crutches with no difficulties
-correct answer_ANS: C A second progress note method is the PIE format. The narrative note
includes P—Problem, I—Intervention, and E—Evaluation. The intervention is "Demonstrated
use of crutches." "Patient went up and down stairs" and "Used crutches with no difficulties"
are examples of the E. "Deficient knowledge regarding crutches" is the P. A nurse is using the
source record and wants to find the daily weights. Where should the nurse look? a. Database
b. Medical history and examination c. Progress notes d. Graphic sheet and flow sheet
, -correct answer_ANS: D In a source record, the patient's chart has a separate section for
each discipline (e.g., nursing, medicine, social work, respiratory therapy) in which to record
data. Graphic sheets and flow sheets are records of repeated observations and
measurements such as vital signs, daily weights, and intake and output. In the
problem-oriented medical record, the database section contains all available assessment
information pertaining to the patient (e.g., history and physical examination, the nurse's
admission history and ongoing assessment, the dietitian's assessment, laboratory reports,
radiologic test results). In the source record, the medical history and examination contain
results of the initial examination performed by the physician, including findings, family
history, confirmed diagnoses, and medical plan of care. In the source record, the progress
notes contain an ongoing record of the patient's progress and response to medical therapy
and a review of the disease process; it often is interdisciplinary and includes documentation
from health-related disciplines (e.g., health care providers, physical therapy, social work). A
nurse is a member of an interdisciplinary team that uses critical pathways. According to the
critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is
day 3, and the patient cannot sit in the chair. What should the nurse do? a. Focus charting
using the DAR format. b. Add this data to the problem list. c. Document the variance in the
patient's record. d. Report a positive variance in the next interdisciplinary team meeting.
-correct answer_ANS: C A variance occurs when the activities on the critical pathway are not
completed as predicted, or the patient does not meet expected outcomes. An example of a
variance is when a patient develops pulmonary complications after surgery, requiring
oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a
patient progresses more rapidly than expected (e.g., use of a Foley catheter may be
discontinued a day early). When a nurse is using the problem-oriented medical record, after
analyzing data, health care team members identify problems and make a single problem list.
A type of narrative format charting is focus charting. It involves the use of DAR notes, which
include D—Data (both subjective and objective), A—Action or nursing intervention, and
R—Response of the patient (i.e., evaluation of effectiveness). A nurse needs to begin
discharge planning for a patient admitted with pneumonia and a congested cough. When is
the best time the nurse should start discharge planning for this patient? a. Upon admission b.
Right before discharge c. After the congestion is treated d. When the primary care provider
writes the order -correct answer_ANS: A Ideally, discharge planning begins at admission.
Right before discharge is too late for discharge planning. After the congestion is treated is
also too late for discharge planning. Usually the primary care provider writes the order too
close to discharge, and nurses do not need an order to begin the teaching that will be
needed for discharge. By identifying discharge needs early, nursing and other health care
professionals can begin planning for home care, support services, and any equipment needs
at home A patient is being discharged home. Which information should the nurse include? a.
Acuity level b. Community resources c. Standardized care plan d. Kardex -correct
answer_ANS: B Discharge documentation includes medications, diet, community resources,
follow-up care, and whom to contact in case of an emergency or for questions. A patient's
acuity level, usually determined by a computer program, is based on the type and number of
nursing interventions (e.g., intravenous [IV] therapy, wound care, ambulation assistance)
required over a 24-hour period. Acuity level can be used for staffing and billing. Some
institutions use standardized care plans to make documentation more efficient. The plans,
based on the institution's standards of nursing practice, are preprinted, established
guidelines used to care for patients who have similar health problems. In some settings, a
Kardex, a portable "flip-over" file or notebook, is kept at the nurses' station. Most Kardex
forms have an activity and treatment section and a nursing care plan section, which organize
information for quick reference. A nurse developed the following discharge summary sheet.
Which critical information should be added? TOPIC DISCHARGE SUMMARY Medication Diet
