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Exam 6: Documentation

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Question 1

Multiple Choice

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The nurse is using the principles of documentation. Which principle should the nurse anticipate to incorporate?

A) Ethics.
B) Accountability.
C) Professionalism.
D) Communication.

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Question 2

Multiple Choice

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A client tells the nurse that their pain is okay now. Which question should the nurse ask the patient to obtain more accurate information?

A) "Do you feel better?"
B) "Can you explain what okay means?"
C) "Are you pain free?"
D) "Is feeling okay a tolerable condition for you?"

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Question 3

Multiple Choice

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The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation?

A client tells the nurse that her mother has type II diabetes. Which information about the patient's mother should the nurse include in genogram?

The nurse is reviewing the charting from the previous shift. Which should the nurse recognize is appropriate to chart?

A client tells the nurse that they have pain in their lower abdomen. Which should the nurse record to reflect accuracy in the documentation of the information?

The nurse manager is discussing the principles of documentation with the nursing staff. Which statement made by a nurse indicates an understanding of the principle of professionalism?

The nurse is using the SBAR tool to notify a healthcare provider about a client that is physically declining. Which statement should the nurse include when communicating the situation?

The nurse is documenting an assessment. Which terms should the nurse be mindful of when recording information to ensure the documentation is accurate and complete? Select all that apply.

The nurse educator is presenting information about the APIE method of charting to the staff nurses. Which statements by the nurses should the preceptor recognize indicates an understanding of the information? Select all that apply.

The nurse is preparing to describe a location in the body in the documentation of an assessment. Which terminology should the nurse anticipate using?

The nurse is preparing to document a client's position that is laying on their back facing the ceiling. Which terminology should the nurse use in the documentation?

The preceptor is reviewing the use of the SBAR tool with a new nurse. Which statement made by the nurse indicates an understanding of the tool?

A client asks the nurse why they are creating a genogram. Which information should the nurse provide the patient with?

The nurse is preparing to create a pedigree for the client using the client's family history information. Which should the nurse recognize are benefits to using a genogram? Select all that apply.

The nurse is reviewing the different types of documentation. Which should the nurse recognize is a benefit to charting by exception?

The nurse is avoiding the use of a client's personally identifiable information. Which information should the nurse recognize should not be used? Select all that apply.

A client tells the nurse that they are experiencing discomfort above their elbow. Which medical terminology should the nurse use to describe the location of discomfort?

The nurse is using the acronym SOAP to record information obtained from a client assessment. Which should the nurse recognize should be recorded in the "S" category?

The nurse manager is reviewing tips for appropriate documentation with the nursing staff. Which statement made by the nursing staff indicates further education is required?