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NURSING:DOCUMENTING, REPORTING, CONFERRING FUNDAMENTALS Q & A 2023.Qualified.DOWNLOAD TO S, Exams of Nursing

NURSING:DOCUMENTING, REPORTING, CONFERRING FUNDAMENTALS Q & A 2023.Qualified.DOWNLOAD TO SCORE A+

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2021/2022

Available from 07/26/2023

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NURSING:DOCUMENTING, REPORTING,
CONFERRING FUNDAMENTALS Q & A
2023.Qualified.DOWNLOAD TO SCORE A+
1.What is the nurse's best defense if a patient alleges nursing negligence?
A) testimony of other nurses
B) testimony of expert witnesses
C) patient's record
D) patient's family
2.A nurse is documenting the intensity of a patient's pain. What would be the most accurate
entry?
A) “Patient complaining of severe pain.”
B) “Patient appears to be in a lot of pain and is crying.”
C) “Patient states has pain; walking in hall with ease.”
D) “Patient states pain is a 9 on a scale of 1 to 10.”
3.Which of the following data entries follows the recommended guidelines for
documenting data?
A) “Patient is overwhelmed by the diagnosis of pancreatic cancer.”
B) “Patient kidneys are producing sufficient amount of measured urine.”
C) “Following oxygen administration, vital signs returned to baseline.”
D) “Patient complained about the quality of the nursing care provided on
previous shift.”
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CONFERRING FUNDAMENTALS Q & A

2023.Qualified.DOWNLOAD TO SCORE A+

1.What is the nurse's best defense if a patient alleges nursing negligence? A) testimony of other nurses B) testimony of expert witnesses C) patient's record D) patient's family 2.A nurse is documenting the intensity of a patient's pain. What would be the most accurate entry? A) “Patient complaining of severe pain.” B) “Patient appears to be in a lot of pain and is crying.” C) “Patient states has pain; walking in hall with ease.” D) “Patient states pain is a 9 on a scale of 1 to 10.” 3.Which of the following data entries follows the recommended guidelines for documenting data? A) “Patient is overwhelmed by the diagnosis of pancreatic cancer.” B) “Patient kidneys are producing sufficient amount of measured urine.” C) “Following oxygen administration, vital signs returned to baseline.” D) “Patient complained about the quality of the nursing care provided on previous shift.”

CONFERRING FUNDAMENTALS Q & A

2023.Qualified.DOWNLOAD TO SCORE A+

4.Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN 5.In which of the following cases should a progress note be written? Select all that apply. A) for any nurse–patient interaction B) when admitting a patient C) when receiving a patient postoperatively D) when assisting a patient with ADLs E) when a procedure is performed F) when a patient sends back an untouched dinner tray 6.A student has reviewed a patient's chart before beginning assigned care. Which of the following actions violates patient confidentiality? A) writing the patient's name on the student care plan B) providing the instructor with plans for care C) discussing the medications with a unit nurse

CONFERRING FUNDAMENTALS Q & A

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9.A patient asks to see his medical record (chart). How would the nurse respond? A) “I can't let you do that without a doctor's order.” B) “Our hospital policy is that you can't do that.” C) “I will get your chart and provide you with privacy to read it.” D) “Why would you want to do that? It will only make you worry.” 10.A physician's order reads “up ad lib.” What does this mean in terms of patient activity? A) may walk twice a day B) may be up as desired C) may only go to the bathroom D) must remain on bed rest

  1. Which of the following abbreviations are on the list of the Joint Commission “do not use” abbreviations? Select all that apply.

CONFERRING FUNDAMENTALS Q & A

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A) U (unit) B) QD (daily) C) NPO (nothing per os) D) mL (milliliters) E) > (greater than) F) mcg (micrograms)

  1. What is the primary purpose of the patient record? A) communication B) advocacy C) research D) education
  2. In what type of documentation method would a nurse document narrative notes in a nursing section? A) problem-oriented medical record B) source-oriented record C) PIE charting system D) focus charting
  3. Which one of the following methods of documentation is organized around patient diagnoses rather than around patient information? A) problem-oriented medical record (POMR) B) source-oriented record C) PIE charting system D) focus charting

CONFERRING FUNDAMENTALS Q & A

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  1. Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse? A) problem-oriented medical record B) charting by exception C) PIE charting system D) focus charting
  2. Which of the following information would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply. A) patient sex B) patient admission date C) patient physical assessment D) patient insurance E) patient history F) patient ethnicity 19.A nurse has access to computerized standardized plans of care. After printing one for a patient, what must be done next? A) Date it and put it in the patient's record. B) Sign it and put it in the Kardex. C) Individualize it to the specific patient. D) Use it as printed, based on common needs. 20.What part of the patient's record is commonly used to document specific patient variables, such as vital signs? A) progress notes

CONFERRING FUNDAMENTALS Q & A

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B) nursing notes C) critical paths D) graphic record 21.A nurse is documenting information about a patient in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? A) PIE system B) minimum data set C) OASIS D) charting by exception 22.What is the primary purpose of an incident report? A) means of identifying risks B) basis for staff evaluation

CONFERRING FUNDAMENTALS Q & A

2023.Qualified.DOWNLOAD TO SCORE A+