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NRS 2024. Exam #1 Review Practice Questions and Answers 2024
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NRS 2024. Exam #1 Review Practice Questions
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NRS 2024. Exam #1 Review PracticeQuestions
Which is not a purpose of the client care record?
a. To serve as a legal document.
b. To facilitate reimbursement
c. To serve as a contract with the client.
d. To assist with care planning. - answerc
Which is the primary purpose of client records?
a. Communication
b. Reimbursement
c. Legal protection
d. Performance improvement - answera
Which note includes all elements of a SOAP note?
a. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea.
Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart
rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic
and reassess within 1 hour for effectiveness.
b. Client reports nausea, vomiting, and diarrhea x 3 days. Denies any sick contacts or
recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of
92 beats/min.
c. Client reports nausea and vomiting x 3 days. Vital signs stable. Most likely due to
gastroenteritis.
d. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will
give an antiemetic and reassess. - answera
A nurse is documenting client care using the SOAP format. Place the statements listed
below in the order that the nurse would record them.
a. "I don't feel well. I've been urinating often, and it burns when I urinate."
b. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees
F. Indwelling urinary catheter removed 2 days ago.
,c. Fever, possible urinary tract infection.
d. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to
monitor temperature. - answer1. a
2. b
3. c
4. d
The charge nurse is reviewing SOAP format documentation with a newly hired nurse.
What information should the charge nurse discuss?
a. Subjective data should be included when documenting.
b. Objective data are what the client states about the problem
c. The plan includes interventions, evaluation, and response
d. Abnormal laboratory values are common items that are documented. - answera
A nurse is following a clinical pathway that guides the care of a client after knee surgery.
When the nurse observes the client vomiting, it creates a deviation from the clinical
pathway. What should the nurse identify this event as?
a. A never event
b. A variance
c. An audit
d. A sentinel event - answerb
A nurse accidentally gives a double dose of blood pressure medication. After ensuring
the safety of the client, the nurse would record the error in which documents?
a. Client's record and occurrence report
b. Occurrence report and clinical pathway
c. Critical pathway and care plan
d. Care plan and client's record - answera
Which statement by the nurse would indicate to the charge nurse that there is need for
further teaching on the purposes of medical records?
a. "The clients' medical records provide data for legal evidence."
b. "I can share the clients' medical records with the health care team."
c. "The clients' medical records are an obstruction to research and education."
d. "The clients' health records should be used to promote reimbursement from
insurance companies" - answerc
The nurse documents that a client does not have pain prior to the administration of pain
medication. The client, however, requested medication for increasing postsurgical pain.
, What is the appropriate action to correct the pain assessment documented in the client's
paper medical record?
a. Scribble through the entry.
b. Obtain white-out to cover the entry.
c. Write over the entry in another color pen.
d. Place one line through the entry and initial it. - answerd
The nurse documents a progress note in the wrong client's electronic medical record
(EMR). Which action would the nurse take once realizing the error?
a. Immediately delete the incorrect documentation.
b. Create an addendum with a correction.
c. Contact information technology (IT) staff to make the correction.
d. Contact the health care provider. - answerb
A nurse manager is discussing a nurse's social media post about an interesting client
situation. The nurse states, "I didn't violate client privacy because I didn't use the client's
name." What response by the nurse manager is most appropriate?
a. "Any information that can identify a person is considered a breach of client privacy."
b. "You may continue to post about a client, as long as you do not use the client's
name."
c. "All aspects of clinical practice are confidential and should not be discussed."
d. "The information being posted on social media is inappropriate. Make sure to discuss
information about clients privately with friends and family." - answera
The nurse is caring for a client whose spouse wishes to see the electronic health
record. What is the appropriate nursing response?
a. "Let me get that for you."
b. "Only authorized persons are allowed to access client records."
c. "The provider will need to give permission for you to review."
d. "I am sorry I can't access that information." - answerb
Which action by the nurse is compliant with the Health Insurance Portability and
Accountability Act (HIPAA)?
a. Disclosing client health information for research purposes after obtaining permission
from the client's health care provider
b. Releasing the client's entire health record when only portions of the information are
needed
c. Submitting a written notice to all clients identifying the uses and disclosures of their
health information
d. Obtaining only the client's verbal acknowledgement of having been informed of the
disclosure of information - answerc
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