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Documentation and Reporting Questions with
Detailed Verified Answers
A client's diagnosis of pneumonia requires treatment with antibiotics. The
corresponding order in the client's chart
should be written as ...
A) Avelox (moxifloxacin) 400 mg daily
B) Avelox (moxifloxacin) 400 mg Q.D.
C) Avelox (moxifloxacin) 400 mg qd
D) Avelox (moxifloxacin) 400 mg OD
Ans: A
The nurses who provide care in a large, long-term care facility utilize charting by
exception (CBE) as the preferred
method of documentation. This documentation method may have which of the
following drawbacks?
A) Vulnerability to legal liability since nurse's safe, routine care is not recorded
B) Increased workload for nurses in order to complete necessary documentation
C) Failure to identify and record client problems and associated interventions
D) Significant differences in the charting between nurses due to lack of standardization
Ans: A
The nurse managers of a home health care office wish to maximize nurses' freedom to
characterize and record client
conditions and situations in the nurses' own terms. Which of the following
documentation formats is most likely to
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promote this goal?
A) Narrative notes
B) SOAP notes
C) Focus charting
D) Charting by exception
Ans: A
A hospital utilizes the SOAP method of charting. Within this model, which of the
nurse's following statements would
appear at the beginning of a charting entry?
A) "Client complaining of abdominal pain rated at 8/10."
B) "Client is guarding her abdomen and occasionally moaning."
C) "Client has a history of recent abdominal pain."
D) "2 mg Dilaudid PO administered with good effect"
Ans: A
What is the nurse's best defense if a client alleges nursing negligence?
A) Testimony of other nurses
B) Testimony of expert witnesses
C) Client's record
D) Client's family
Ans: C
A nurse is documenting the intensity of a client's pain. What would be the most
accurate entry?
A) "Client complaining of severe pain."
B) "Client appears to be in a lot of pain and is crying."
© Get it right 2025 Getaway - Stuvia US All rights reserved
Documentation and Reporting Questions with
Detailed Verified Answers
A client's diagnosis of pneumonia requires treatment with antibiotics. The
corresponding order in the client's chart
should be written as ...
A) Avelox (moxifloxacin) 400 mg daily
B) Avelox (moxifloxacin) 400 mg Q.D.
C) Avelox (moxifloxacin) 400 mg qd
D) Avelox (moxifloxacin) 400 mg OD
Ans: A
The nurses who provide care in a large, long-term care facility utilize charting by
exception (CBE) as the preferred
method of documentation. This documentation method may have which of the
following drawbacks?
A) Vulnerability to legal liability since nurse's safe, routine care is not recorded
B) Increased workload for nurses in order to complete necessary documentation
C) Failure to identify and record client problems and associated interventions
D) Significant differences in the charting between nurses due to lack of standardization
Ans: A
The nurse managers of a home health care office wish to maximize nurses' freedom to
characterize and record client
conditions and situations in the nurses' own terms. Which of the following
documentation formats is most likely to
© Get it right 2025 Getaway - Stuvia US All rights reserved
, Click here for more: Scholars nexus
promote this goal?
A) Narrative notes
B) SOAP notes
C) Focus charting
D) Charting by exception
Ans: A
A hospital utilizes the SOAP method of charting. Within this model, which of the
nurse's following statements would
appear at the beginning of a charting entry?
A) "Client complaining of abdominal pain rated at 8/10."
B) "Client is guarding her abdomen and occasionally moaning."
C) "Client has a history of recent abdominal pain."
D) "2 mg Dilaudid PO administered with good effect"
Ans: A
What is the nurse's best defense if a client alleges nursing negligence?
A) Testimony of other nurses
B) Testimony of expert witnesses
C) Client's record
D) Client's family
Ans: C
A nurse is documenting the intensity of a client's pain. What would be the most
accurate entry?
A) "Client complaining of severe pain."
B) "Client appears to be in a lot of pain and is crying."
© Get it right 2025 Getaway - Stuvia US All rights reserved
