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Exam (elaborations)

Documenting and Reporting- Foundations Questions with Complete Solutions

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  • Nursing Reporting- Foundations

Documenting and Reporting- Foundations Questions with Complete Solutions How should a nurse document a patient’s pain level? Use a standardized pain scale, note the level of pain reported, any relevant descriptions, and the effectiveness of interventions provided. What is the purpose...

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  • September 1, 2024
  • 22
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • Nursing Reporting- Foundations
  • Nursing Reporting- Foundations
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BrilliantScores
Documenting and Reporting-
Foundations Questions with Complete
Solutions
How should a nurse document a patient’s pain level?


✔✔ Use a standardized pain scale, note the level of pain reported, any relevant descriptions, and

the effectiveness of interventions provided.




What is the purpose of documenting nursing assessments?


✔✔ To record the patient’s physical and emotional status, track changes over time, and guide

ongoing care planning.




How should a nurse document unusual or adverse events?


✔✔ Clearly describe the event, including the time, place, individuals involved, and any

immediate actions taken, while avoiding speculation or blame.




What should be included in a discharge summary?


✔✔ Patient’s condition at discharge, instructions for follow-up care, medications prescribed, and

any specific recommendations or precautions.




1

,How can a nurse ensure confidentiality when documenting patient information?


✔✔ Use secure systems for electronic records, avoid leaving paper documents in accessible

areas, and follow policies for handling sensitive information.




What is the importance of documenting a patient’s response to treatment?


✔✔ To evaluate the effectiveness of the treatment, guide future care decisions, and provide a

record for continuity of care.




How should a nurse document communication with a patient’s family?


✔✔ Record the details of the conversation, including the date, time, the topics discussed, and the

family’s questions or concerns.




What information should be included in an incident report?


✔✔ The nature of the incident, involved individuals, any immediate actions taken, and the

impact on patient care or safety.




How should a nurse document a patient’s refusal to participate in a recommended procedure?


✔✔ Note the patient’s refusal, the rationale provided, any potential consequences discussed, and

any alternative plans made.

2

, What should be included in documentation of a patient’s nutritional intake?


✔✔ Record the types and amounts of food and fluids consumed, any dietary restrictions, and

observations related to the patient’s nutritional status.




How should a nurse document the outcome of a patient’s diagnostic test?


✔✔ Include the test results, the date and time of the test, and any follow-up actions or

interpretations related to the results.




What is the primary goal of nursing documentation?


✔✔ To provide an accurate and comprehensive record of patient care and treatment.




How should a nurse document a patient’s refusal of medication?


✔✔ Note the patient’s refusal, the reason given, and any actions taken to address or educate the

patient.




What should be included in a nursing progress note?


✔✔ The patient’s current condition, any changes in status, interventions performed, and the

outcomes of those interventions.

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