Documentation and Reporting Test Questions and
Answers Rated A
A client's diagnosis of pneumonia requires appear at the beginning of a charting entry?
treatment with antibiotics. The corresponding A) "Client complaining of abdominal pain rated at
order in the client's chart 8/10."
should be written as ... B) "Client is guarding her abdomen and
A) Avelox (moxifloxacin) 400 mg daily occasionally moaning."
B) Avelox (moxifloxacin) 400 mg Q.D. C) "Client has a history of recent abdominal
C) Avelox (moxifloxacin) 400 mg qd pain."
D) Avelox (moxifloxacin) 400 mg OD - D) "2 mg Dilaudid PO administered with good
ANSWER -A effect" - ANSWER -A
The nurses who provide care in a large, long- What is the nurse's best defense if a client
term care facility utilize charting by exception alleges nursing negligence?
(CBE) as the preferred A) Testimony of other nurses
method of documentation. This documentation B) Testimony of expert witnesses
method may have which of the following C) Client's record
drawbacks? D) Client's family - ANSWER -C
A) Vulnerability to legal liability since nurse's
safe, routine care is not recorded
B) Increased workload for nurses in order to A nurse is documenting the intensity of a client's
complete necessary documentation pain. What would be the most accurate entry?
C) Failure to identify and record client problems A) "Client complaining of severe pain."
and associated interventions B) "Client appears to be in a lot of pain and is
D) Significant differences in the charting between crying."
nurses due to lack of standardization - C) "Client states has pain; walking in hall with
ANSWER -A ease."
D) "Client states pain is a 9 on a scale of 1 to 10."
- ANSWER -D
The nurse managers of a home health care office
wish to maximize nurses' freedom to
characterize and record client Which of the following data entries follows the
conditions and situations in the nurses' own recommended guidelines for documenting data?
terms. Which of the following documentation A) "Client is overwhelmed by the diagnosis of
formats is most likely to pancreatic cancer."
promote this goal? B) "Client's kidneys are producing sufficient
A) Narrative notes amount of measured urine."
B) SOAP notes C) "Following oxygen administration, vital signs
C) Focus charting returned to baseline."
D) Charting by exception - ANSWER -A D) "Client complained about the quality of the
nursing care provided on previous shift." -
ANSWER -C
A hospital utilizes the SOAP method of charting.
Within this model, which of the nurse's following
statements would Alice Jones, a registered nurse, is documenting
1/5
, Documentation and Reporting Test Questions and
Answers Rated A
assessments at the beginning of her shift. How C) Client's chief complaint
should she sign the entry? D) Client interventions - ANSWER -A
A) Alice J, RN
B) A. Jones, RN
C) Alice Jones Which of the following methods of documenting
D) AJRN - ANSWER -B client data is least likely to hold up in court if a
case of negligence is
brought against a nurse?
A student has reviewed a client's chart before A) Problem-oriented medical record
beginning assigned care. Which of the following B) Charting by exception
actions violates client C) PIE charting system
confidentiality? D) Focus charting - ANSWER -B
A) Writing the client's name on the student care
plan
B) Providing the instructor with plans for care In what type of documentation method would a
C) Discussing the medications with a unit nurse nurse document narrative notes in a nursing
D) Providing information to the physician about section?
laboratory data - ANSWER -A A) Problem-oriented medical record
B) Source-oriented record
C) PIE charting system
A physician's order reads "up ad lib." What does D) Focus charting - ANSWER -B
this mean in terms of client activity?
A) May walk twice a day
B) May be up as desired A nurse has access to computerized
C) May only go to the bathroom standardized plans of care. After printing one for
D) Must remain on bed rest - ANSWER -B a client, what must be done next?
A) Date it and put it in the client's record.
B) Sign it and put it in the Kardex.
Which one of the following methods of C) Individualize it to the specific client.
documentation is organized around client D) Use it as printed, based on common needs. -
diagnoses rather than around patient ANSWER -C
information?
A) Problem-oriented medical record (POMR)
B) Source-oriented record What part of the client's record is commonly used
C) PIE charting system to document specific client variables, such as
D) focus charting - ANSWER -A vital signs?
A) Progress notes
B) Nursing notes
A nurse organizes client data using the SOAP C) Critical paths
format. Which of the following would be recorded D) Graphic record - ANSWER -D
under "S" of this
acronym?
A) Client complaints of pain A nurse is documenting information about a client
B) Client history in a long-term care facility. What is used in a
2/5
Answers Rated A
A client's diagnosis of pneumonia requires appear at the beginning of a charting entry?
treatment with antibiotics. The corresponding A) "Client complaining of abdominal pain rated at
order in the client's chart 8/10."
should be written as ... B) "Client is guarding her abdomen and
A) Avelox (moxifloxacin) 400 mg daily occasionally moaning."
B) Avelox (moxifloxacin) 400 mg Q.D. C) "Client has a history of recent abdominal
C) Avelox (moxifloxacin) 400 mg qd pain."
D) Avelox (moxifloxacin) 400 mg OD - D) "2 mg Dilaudid PO administered with good
ANSWER -A effect" - ANSWER -A
The nurses who provide care in a large, long- What is the nurse's best defense if a client
term care facility utilize charting by exception alleges nursing negligence?
(CBE) as the preferred A) Testimony of other nurses
method of documentation. This documentation B) Testimony of expert witnesses
method may have which of the following C) Client's record
drawbacks? D) Client's family - ANSWER -C
A) Vulnerability to legal liability since nurse's
safe, routine care is not recorded
B) Increased workload for nurses in order to A nurse is documenting the intensity of a client's
complete necessary documentation pain. What would be the most accurate entry?
C) Failure to identify and record client problems A) "Client complaining of severe pain."
and associated interventions B) "Client appears to be in a lot of pain and is
D) Significant differences in the charting between crying."
nurses due to lack of standardization - C) "Client states has pain; walking in hall with
ANSWER -A ease."
D) "Client states pain is a 9 on a scale of 1 to 10."
- ANSWER -D
The nurse managers of a home health care office
wish to maximize nurses' freedom to
characterize and record client Which of the following data entries follows the
conditions and situations in the nurses' own recommended guidelines for documenting data?
terms. Which of the following documentation A) "Client is overwhelmed by the diagnosis of
formats is most likely to pancreatic cancer."
promote this goal? B) "Client's kidneys are producing sufficient
A) Narrative notes amount of measured urine."
B) SOAP notes C) "Following oxygen administration, vital signs
C) Focus charting returned to baseline."
D) Charting by exception - ANSWER -A D) "Client complained about the quality of the
nursing care provided on previous shift." -
ANSWER -C
A hospital utilizes the SOAP method of charting.
Within this model, which of the nurse's following
statements would Alice Jones, a registered nurse, is documenting
1/5
, Documentation and Reporting Test Questions and
Answers Rated A
assessments at the beginning of her shift. How C) Client's chief complaint
should she sign the entry? D) Client interventions - ANSWER -A
A) Alice J, RN
B) A. Jones, RN
C) Alice Jones Which of the following methods of documenting
D) AJRN - ANSWER -B client data is least likely to hold up in court if a
case of negligence is
brought against a nurse?
A student has reviewed a client's chart before A) Problem-oriented medical record
beginning assigned care. Which of the following B) Charting by exception
actions violates client C) PIE charting system
confidentiality? D) Focus charting - ANSWER -B
A) Writing the client's name on the student care
plan
B) Providing the instructor with plans for care In what type of documentation method would a
C) Discussing the medications with a unit nurse nurse document narrative notes in a nursing
D) Providing information to the physician about section?
laboratory data - ANSWER -A A) Problem-oriented medical record
B) Source-oriented record
C) PIE charting system
A physician's order reads "up ad lib." What does D) Focus charting - ANSWER -B
this mean in terms of client activity?
A) May walk twice a day
B) May be up as desired A nurse has access to computerized
C) May only go to the bathroom standardized plans of care. After printing one for
D) Must remain on bed rest - ANSWER -B a client, what must be done next?
A) Date it and put it in the client's record.
B) Sign it and put it in the Kardex.
Which one of the following methods of C) Individualize it to the specific client.
documentation is organized around client D) Use it as printed, based on common needs. -
diagnoses rather than around patient ANSWER -C
information?
A) Problem-oriented medical record (POMR)
B) Source-oriented record What part of the client's record is commonly used
C) PIE charting system to document specific client variables, such as
D) focus charting - ANSWER -A vital signs?
A) Progress notes
B) Nursing notes
A nurse organizes client data using the SOAP C) Critical paths
format. Which of the following would be recorded D) Graphic record - ANSWER -D
under "S" of this
acronym?
A) Client complaints of pain A nurse is documenting information about a client
B) Client history in a long-term care facility. What is used in a
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