Page 1 of 33
NUR209 EXAM 2 LATEST 2025 ACTUAL EXAM|
MEDICAL- SURGICAL NURSING II EXAM 2 WITH
COMPLETE REAL EXAM QUESTIONS AND CORRECT
VERIFIED ANSWERS/ ALREADY GRADED A+ (NEWEST!!)
Communication with team .....ANSWER..... Clear, accurate, up to
date patient documentation is cornerstone for safe delivery
providing flow on info btw providers of care
- communicates plan of care and patient progress to all
healthcare team members
- conveys clear picture of patient through diff viewpoints and at
diff times
- ensures continuity of care and provides data for evaluation and
revision or continuation of care
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Electronic Medical Record (EMR) characteristics .....ANSWER.....
Most clinical agencies have computer used part or all of the
patients record in an EHR. EHR provides a mean to collect and
share patient data electronically so it can be analyzed to
improve outcomes. It allows for standardization of documentation
across healthcare team and to be viewed simultaneously
Documenting v Reporting .....ANSWER..... Know the diff
Documenting .....ANSWER..... handwritten, typed or electronic
communication or documentation is a form of written
communication and serves as a permanent record of pt info and
care provided by all members of healthcare team
Reporting .....ANSWER..... Form of verbal communication and
takes place when 2 or more people share info about patient
care
- face to face (team meeting, transfer of care, change of shift,
handoff)
,Page 3 of 33
- telephone (reports to a case manager of provider from nurse
making home visits )
objective data .....ANSWER..... Observable and measurable pt
data collected during physical assessment
- observed through senses of sight, hearing, touch, smell
- Ex:
- BP 128/82 mm Hg
- pulse: 57 bpm
- skin pale and cool to touch
subjective data .....ANSWER..... "S" for their "Symptoms"
Pts feelings about their health problems
- cannot be observed by nurse
Ex's:
- "I feel dizzy"
, Page 4 of 33
- "I have a sharp pain in my stomach"
Why do we document? What is the point? Why do we document
immediately? .....ANSWER..... Real time documentation - take BP
and document immediately
Why: accuracy and safety
When assessing a patient, how do we document current state?
"Patient appears angry" but OBJECTIVELY .....ANSWER..... Using
direct quotes of patient statements can help maintain objectivity
!!!!
→ actual pt behavior should be described rather than making
interpretations!!!!
- avoid interpretations like "pt appears angry"
Ex:
NUR209 EXAM 2 LATEST 2025 ACTUAL EXAM|
MEDICAL- SURGICAL NURSING II EXAM 2 WITH
COMPLETE REAL EXAM QUESTIONS AND CORRECT
VERIFIED ANSWERS/ ALREADY GRADED A+ (NEWEST!!)
Communication with team .....ANSWER..... Clear, accurate, up to
date patient documentation is cornerstone for safe delivery
providing flow on info btw providers of care
- communicates plan of care and patient progress to all
healthcare team members
- conveys clear picture of patient through diff viewpoints and at
diff times
- ensures continuity of care and provides data for evaluation and
revision or continuation of care
,Page 2 of 33
Electronic Medical Record (EMR) characteristics .....ANSWER.....
Most clinical agencies have computer used part or all of the
patients record in an EHR. EHR provides a mean to collect and
share patient data electronically so it can be analyzed to
improve outcomes. It allows for standardization of documentation
across healthcare team and to be viewed simultaneously
Documenting v Reporting .....ANSWER..... Know the diff
Documenting .....ANSWER..... handwritten, typed or electronic
communication or documentation is a form of written
communication and serves as a permanent record of pt info and
care provided by all members of healthcare team
Reporting .....ANSWER..... Form of verbal communication and
takes place when 2 or more people share info about patient
care
- face to face (team meeting, transfer of care, change of shift,
handoff)
,Page 3 of 33
- telephone (reports to a case manager of provider from nurse
making home visits )
objective data .....ANSWER..... Observable and measurable pt
data collected during physical assessment
- observed through senses of sight, hearing, touch, smell
- Ex:
- BP 128/82 mm Hg
- pulse: 57 bpm
- skin pale and cool to touch
subjective data .....ANSWER..... "S" for their "Symptoms"
Pts feelings about their health problems
- cannot be observed by nurse
Ex's:
- "I feel dizzy"
, Page 4 of 33
- "I have a sharp pain in my stomach"
Why do we document? What is the point? Why do we document
immediately? .....ANSWER..... Real time documentation - take BP
and document immediately
Why: accuracy and safety
When assessing a patient, how do we document current state?
"Patient appears angry" but OBJECTIVELY .....ANSWER..... Using
direct quotes of patient statements can help maintain objectivity
!!!!
→ actual pt behavior should be described rather than making
interpretations!!!!
- avoid interpretations like "pt appears angry"
Ex:
