FON Unit 2 questions and answers
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What is the primary purpose of the health record? - correct answer ✔✔ To provide a clear
understanding of the patient and facilitate communication among the interprofessional team.
What does SBARR stand for in nursing communication? - correct answer ✔✔ Situation,
Background, Assessment, Recommendation, and Read back.
What information should be obtained when receiving a telephone order? - correct answer ✔✔
Confirm the client's identity, allergies, and ensure all prescriptions are complete.
What are the key guidelines for accurate documentation in a health record? - correct answer
✔✔ Documentation must be clear, accurate, concise, timely, and should include patient
responses and interventions.
What are the legal considerations related to documentation in a health record? - correct answer
✔✔ Documentation must be objective, avoid assumptions, and uphold confidentiality to
comply with HIPAA.
What are the phases of the nursing process? - correct answer ✔✔ Assessment, Diagnosis,
Planning, Implementation, and Evaluation.
How does Maslow's Hierarchy of Needs apply to nursing practice? - correct answer ✔✔ It helps
prioritize patient care based on their basic needs and psychological well-being.
What information should be included in a transfer report? - correct answer ✔✔ Patient's
current condition, treatment received, and any specific needs or concerns.
, What are the nurse's responsibilities during admission, transfer, and discharge? - correct answer
✔✔ To ensure proper documentation, patient education, and continuity of care.
What are the charting rules for nursing documentation? - correct answer ✔✔ Use correct
patient identifiers, approved abbreviations, chart after care, and avoid empty lines.
What should be done if a late entry is made in documentation? - correct answer ✔✔ Identify it
as a 'late entry,' specify the event time, and ensure it is signed and dated.
How should errors in documentation be corrected? - correct answer ✔✔ Keep the original
document, draw a line through the error, write 'error' with initials, and document the correct
information.
What are common medical abbreviations used in nursing documentation? - correct answer ✔✔
Examples include ac (before meals), pc (after meals), PO (by mouth), and PRN (as needed).
What is the purpose of interprofessional communication and reporting? - correct answer ✔✔ To
provide continuity of care and enhance communication among team members.
What is the Medication Administration Record (MAR)? - correct answer ✔✔ A document that
records all medications administered to a patient, which can be paper or electronic.
What are the documentation formats used in healthcare? - correct answer ✔✔ Source-
oriented, problem-oriented, PIE model, focus charting, and charting by exception.
What is the significance of timely documentation in nursing? - correct answer ✔✔ It ensures
accurate patient care records and is essential for reimbursement.
rated A+
What is the primary purpose of the health record? - correct answer ✔✔ To provide a clear
understanding of the patient and facilitate communication among the interprofessional team.
What does SBARR stand for in nursing communication? - correct answer ✔✔ Situation,
Background, Assessment, Recommendation, and Read back.
What information should be obtained when receiving a telephone order? - correct answer ✔✔
Confirm the client's identity, allergies, and ensure all prescriptions are complete.
What are the key guidelines for accurate documentation in a health record? - correct answer
✔✔ Documentation must be clear, accurate, concise, timely, and should include patient
responses and interventions.
What are the legal considerations related to documentation in a health record? - correct answer
✔✔ Documentation must be objective, avoid assumptions, and uphold confidentiality to
comply with HIPAA.
What are the phases of the nursing process? - correct answer ✔✔ Assessment, Diagnosis,
Planning, Implementation, and Evaluation.
How does Maslow's Hierarchy of Needs apply to nursing practice? - correct answer ✔✔ It helps
prioritize patient care based on their basic needs and psychological well-being.
What information should be included in a transfer report? - correct answer ✔✔ Patient's
current condition, treatment received, and any specific needs or concerns.
, What are the nurse's responsibilities during admission, transfer, and discharge? - correct answer
✔✔ To ensure proper documentation, patient education, and continuity of care.
What are the charting rules for nursing documentation? - correct answer ✔✔ Use correct
patient identifiers, approved abbreviations, chart after care, and avoid empty lines.
What should be done if a late entry is made in documentation? - correct answer ✔✔ Identify it
as a 'late entry,' specify the event time, and ensure it is signed and dated.
How should errors in documentation be corrected? - correct answer ✔✔ Keep the original
document, draw a line through the error, write 'error' with initials, and document the correct
information.
What are common medical abbreviations used in nursing documentation? - correct answer ✔✔
Examples include ac (before meals), pc (after meals), PO (by mouth), and PRN (as needed).
What is the purpose of interprofessional communication and reporting? - correct answer ✔✔ To
provide continuity of care and enhance communication among team members.
What is the Medication Administration Record (MAR)? - correct answer ✔✔ A document that
records all medications administered to a patient, which can be paper or electronic.
What are the documentation formats used in healthcare? - correct answer ✔✔ Source-
oriented, problem-oriented, PIE model, focus charting, and charting by exception.
What is the significance of timely documentation in nursing? - correct answer ✔✔ It ensures
accurate patient care records and is essential for reimbursement.
