Question 1

The nursing instructor is reviewing the different types of charting methods with the class.Which should the instructor explain for the acronym SOAPIER?
A)Symptoms, Objective, Assessment data, Plan, Intervention, Evaluation, Revision
B)Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Results
C)Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision
D)Subjective data, Objective data, Assessment data, Problems, Intervention, Evaluation, Revision

Accepted Answer

SOAPIER stands for Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision. This acronym is used to outline a comprehensive method of charting in the medical field, ensuring all aspects of patient care are documented systematically.

Question 2

The nurse completes documentation on an electronic medical record.What should the nurse do next?
A)Log out of the system.
B)Discard the report form.
C)Prepare to give the report to the next nurse.
D)Answer call lights and provide medication.

Accepted Answer

Logging out of the system ensures patient confidentiality and data security, which are critical in healthcare settings.

Question 3

A health-care facility uses narrative charting.What should the nurse remember when following this documentation approach?
A)It tells the client's story.
B)It focuses on data, action, and response.
C)It is the least thorough documentation method.
D)It is the least time-consuming documentation method.

Accepted Answer

Narrative charting involves writing detailed notes that tell the client's story, capturing the sequence of events and the nurse's observations and actions.

Question 4

A resident is being admitted to the skilled nursing facility.Which documentation is required to be completed for this client?
A)Kardex
B)Care plan
C)Advance directive
D)Minimum data set

Accepted Answer

The Minimum Data Set (MDS) is a federally mandated assessment tool that must be completed for residents in skilled nursing facilities to ensure proper care planning and reimbursement.

Question 5

Information about the Health Insurance Portability and Accountability Act (HIPAA)is being prepared for a group of new nurses to review during orientation.Which should be emphasized about this act? Select all that apply.
A)HIPAA guarantees a client the right to view and obtain a copy of his or her medical record.
B)HIPAA guarantees a client the right to take the original medical chart.
C)HIPAA asks a client to specify who can obtain personal health data.
D)HIPAA ensures the right of a client to amend personal health information.
E)HIPAA requires hospitals to disclose the way in which a client's health data will be used.

Accepted Answer

HIPAA provides patients the right to access and obtain copies of their medical records, specify who can access their health data, amend their personal health information, and requires hospitals to disclose how health data will be used. It does not allow clients to take the original medical chart.

Question 6

A client received a dose of intravenous pain medication before change of shift.After receiving the report, the oncoming nurse notes that the medication was not documented, provides another dose, and the client has a respiratory arrest.Who is most liable for this situation?
A)The nurse who gave the first dose of medication
B)The nurse who gave the second dose of medication
C)The health-care provider who prescribed the medication
D)The person who called the nurse away before documenting the medication

Accepted Answer

The answer of A client received a dose of intravenous...

Question 7

The nurse notices that there is no room at the end of a written note to sign the note.What should the nurse do?
A)Initial each line of the note.
B)Initial at the end of the note.
C)Draw a line through the space on the next line and sign at the end.
D)Draw a parenthesis around the entire note and sign and credential it in the margin.

Accepted Answer

Drawing a line through the remaining space on the next line and then signing at the end is a common practice to prevent anyone from adding unauthorized information after the note has been completed. This ensures the integrity of the documented information.

Question 8

The nurse receives a login and password to access the electronic medical record.Where should the nurse store this information?
A)Tape it to the inside of the locker door.
B)Tape it to the underside of the keyboard.
C)Place it in the pocket protector used for care.
D)Place it in the wallet that is locked up during the shift.

Accepted Answer

Storing login and password information in a locked wallet during the shift ensures the information is kept secure and confidential, adhering to privacy and security policies for sensitive information.

Question 9

The director of a home care agency is scheduling staff to make home visits.Which staff member should visit a client newly admitted to the agency for care?
A)Agency director
B)Registered nurse
C)Nursing assistant
D)Licensed practical/vocational nurse

Accepted Answer

A registered nurse (RN) should visit a client newly admitted to the agency for care to perform an initial assessment, develop a care plan, and determine the level of care needed. RNs have the education and authority to conduct comprehensive assessments and initiate care plans.

Question 10

The staff members at a hospital are preparing for a visit from The Joint Commission (TJC).Which should be explained to the staff about the purpose of this visit? Select all that apply.
A)TJC acts as an insurance company by offering reimbursement to hospitals.
B)TJC seeks to improve the safety and quality of care that health-care organizations provide to the public.
C)TJC offers accreditation when a facility practices in a manner that meets TJC standards.
D)TJC sends a team of reviewers to visit the facility and assess its policies, procedures, and actual performance.
E)TJC sets the standards by which the quality of health care is managed nationally and internationally.

Accepted Answer

The Joint Commission (TJC) aims to improve safety and quality of care, offers accreditation based on standards, sends reviewers to assess facilities, and sets healthcare quality standards. It is not an insurance company.

Question 11

The nursing instructor is reviewing documentation with a group of students.Which should the instructor include as the purpose of written documentation? Select all that apply.
A)Communicate pertinent data to the health-care team
B)Serve as a record of accountability for accreditation
C)Serve as a legal record for the health-care provider only
D)Serve as a record of accountability for quality assurance and reimbursement purposes
E)Provide a permanent record of medical and nursing diagnoses

Accepted Answer

Written documentation in nursing serves multiple purposes: it communicates important data to the healthcare team, acts as a record for accountability and accreditation, supports quality assurance and reimbursement, and provides a permanent record of medical and nursing diagnoses.

Question 12

The nurse discovers a client lying on the floor.Which should the nurse write when completing an incident report?
A)"Client fell out of bed onto the floor."
B)"Heard client fall from the bed to the floor."
C)"Client accidentally fell out of bed onto the floor."
D)"Found client lying face down on the floor beside the bed."

Accepted Answer

Option D is the most objective and factual statement, describing exactly what was observed without implying causation or making assumptions. Incident reports should be based on direct observations and facts.

Question 13

The nurse reviews pertinent laboratory data and assesses the response to pain medication.Where should the nurse write this information until able to document it in the medical record?
A)Report form
B)Bedside clipboard
C)Intake and output record
D)Medication administration record

Accepted Answer

The report form is the appropriate place for a nurse to write down observations and assessments temporarily until they can be documented in the medical record. This ensures the information is communicated effectively among healthcare providers and is eventually recorded in a more permanent and official format.

Question 14

A health-care organization is considering focus charting.Which categories are commonly documented using this approach?
A)Data, action, response
B)Abnormal findings and checklist
C)Problem, intervention, evaluation
D)Subjective, objective, assessment, plan

Accepted Answer

Focus charting commonly uses the categories of Data, Action, and Response (DAR) to document patient care.

Question 15

While documenting in a client's chart, the nurse realizes that it is the wrong chart.What should the nurse do?
A)Write over the incorrect letters.
B)Use correction fluid to blank out the mistaken entry.
C)Use correction tape to blank out the mistaken entry.
D)Write "mistaken entry" and place initials just above incorrect entry.

Accepted Answer

The correct action when a nurse realizes a mistake has been made in a client's chart is to write "mistaken entry" and place their initials just above the incorrect entry. This maintains the integrity of the medical record while clearly indicating that an error was made. Altering the record with correction fluid, tape, or writing over the mistake is not appropriate as it can raise questions about the accuracy and honesty of the documentation.

Question 16

The nursing instructor is asked to prepare an educational program on incidents that have occurred on a specific care area.Which is the most cost-effective approach for the instructor to collect information to support the educational program?
A)Complete a database search through the electronic medical record.
B)Meet with risk management to review incident reports for the care area.
C)Ask the nurse manager to provide specific data regarding client incidents.
D)Access a quality assurance website to obtain information about common incidents.

Accepted Answer

The answer of The nursing instructor is asked to prepare...

Question 17

The nurse uses a cheat sheet to jot down pertinent client data while providing care.What should the nurse do with the sheet after documenting all client care?
A)Shred the paper.
B)Throw it in the trash.
C)Keep the paper for use the next day.
D)Give the paper to the next nurse during hand off communication.

Accepted Answer

Shredding the paper is the correct action because it contains client data, which is confidential. Proper disposal through shredding ensures that the information is protected according to privacy laws and regulations, such as HIPAA in the United States.

Question 18

A hospital's risk-management team provides the nursing staff with an in-service about incident reports.Which information should be included? Select all that apply.
A)An incident report always involves the client.
B)Incident reports are part of the client's medical record.
C)A medication error should be documented on an incident report.
D)A client, visitor, or employee injury should be documented on an incident report.
E)An incident report is used to document out-of-the-ordinary things that happen in a health-care facility.

Accepted Answer

Incident reports are used to document any out-of-the-ordinary events, including medication errors and injuries to clients, visitors, or employees, to improve safety and procedures within a healthcare facility. They are not part of the client's medical record and do not always involve the client.

Question 19

The nurse caring for residents of a skilled nursing facility wants to quickly check on the latest orders and medications for one client.Where should the nurse locate this information?
A)The clipboard
B)The Kardex
C)The medical record
D)The medication administration record

Accepted Answer

The Kardex is a quick reference tool used by nurses to access important information about a patient's care, including the latest orders and medications.

Question 20

The nurse is preparing to document care provided in the client's electronic medical record.Which should the nurse keep in mind when entering the data?
A)Avoid using abbreviations within the note.
B)Document "not observed" to prevent any blank lines.
C)Copy and paste pertinent data from the previous note.
D)Quantify statements by using the words "average" or "normal."

Accepted Answer

Using abbreviations in medical records can lead to misunderstandings or misinterpretations, so it's important to avoid them to ensure clarity and accuracy in documentation.

Quiz 5: Documentation

The nursing instructor is reviewing the different types of charting methods with the class.Which should the instructor explain for the acronym SOAPIER?

The nurse completes documentation on an electronic medical record.What should the nurse do next?

A health-care facility uses narrative charting.What should the nurse remember when following this documentation approach?

A resident is being admitted to the skilled nursing facility.Which documentation is required to be completed for this client?

Information about the Health Insurance Portability and Accountability Act (HIPAA) is being prepared for a group of new nurses to review during orientation.Which should be emphasized about this act? Select all that apply.

A client received a dose of intravenous pain medication before change of shift.After receiving the report, the oncoming nurse notes that the medication was not documented, provides another dose, and the client has a respiratory arrest.Who is most liable for this situation?

The nurse notices that there is no room at the end of a written note to sign the note.What should the nurse do?

The nurse receives a login and password to access the electronic medical record.Where should the nurse store this information?

The director of a home care agency is scheduling staff to make home visits.Which staff member should visit a client newly admitted to the agency for care?

The staff members at a hospital are preparing for a visit from The Joint Commission (TJC) .Which should be explained to the staff about the purpose of this visit? Select all that apply.

The nursing instructor is reviewing documentation with a group of students.Which should the instructor include as the purpose of written documentation? Select all that apply.

The nurse discovers a client lying on the floor.Which should the nurse write when completing an incident report?

The nurse reviews pertinent laboratory data and assesses the response to pain medication.Where should the nurse write this information until able to document it in the medical record?

A health-care organization is considering focus charting.Which categories are commonly documented using this approach?

While documenting in a client's chart, the nurse realizes that it is the wrong chart.What should the nurse do?

The nursing instructor is asked to prepare an educational program on incidents that have occurred on a specific care area.Which is the most cost-effective approach for the instructor to collect information to support the educational program?

The nurse uses a cheat sheet to jot down pertinent client data while providing care.What should the nurse do with the sheet after documenting all client care?

A hospital's risk-management team provides the nursing staff with an in-service about incident reports.Which information should be included? Select all that apply.

The nurse caring for residents of a skilled nursing facility wants to quickly check on the latest orders and medications for one client.Where should the nurse locate this information?

The nurse is preparing to document care provided in the client's electronic medical record.Which should the nurse keep in mind when entering the data?