NRS-2024 FUNDAMENTAL Exam
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's
following statements would appear at the beginning of a charting entry? correct
answers Client complaining of abdominal pain rated at 8/10.
A nurse organizes client data using the SOAP format. Which of the following would be
recorded under "S" of this acronym? correct answers Client complaints of pain
Which note includes all elements of a SOAP note? correct answers 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.
The charge nurse is reviewing SOAP format documentation with a newly hired nurse.
What information should the charge nurse discuss? correct answers Subjective data
should be included when documenting.
What is the nurse's best defense if a patient alleges nursing negligence? correct
answers patients record
A student has reviewed a client's chart before beginning assigned care. Which of the
following actions violates client confidentiality? correct answers Writing the client's
name on the student care plan
What is confidential information? correct answers All information about patients is
considered private or confidential, whether written on paper, saved on a computer, or
spoken aloud. This includes patient names and all identifiers such as address,
telephone and fax number, Social Security number, and any other personal information.
It also includes the reason the patient is sick or in the hospital, office, or clinic, the
assessments and treatments the patient receives, and information about past health
conditions
T/F. A nurse who fails to log off a computer after documenting patient care has
breached patient confidentiality correct answers True
What is the primary purpose of the client record? correct answers Communication
What are other purposes of client record? correct answers Diagnostic and therapeutic
orders, Care planning, Quality process and performance improvement, Research,
decision analysis, Education, Credentialing, regulation, and legislation; Reimbursement
[used to demonstrate to payers (e.g., insurance companies) that patients received the
, intensity and quality of care for which reimbursement is being sought], and Legal and
historical documentation (for court hearing)
What is the purpose of progress notes? correct answers The purpose of progress notes
is to inform caregivers of the progress a patient is making toward achieving expected
outcomes.
The method used to record the patient's progress depends on what? correct answers
The method used to record the patient's progress depends on the documentation
system being used. Common examples include narrative nursing notes, SOAP notes,
PIE notes, focus charting, CBE, and the case management model
What is a critical pathway & where is used? correct answers Collaborative pathways—
also called critical pathways or care maps—are used in the case management model.
The collaborative pathway specifies the care plan linked to expected outcomes along a
timeline. It is a standardized care plan that is developed for a patient population with a
designated diagnosis or procedure. It includes expected outcomes, a list of
interventions to be performed, and the sequence and timing of those interventions.
T/F. CBE is frequently used with collaborative pathway documentation systems. correct
answers True
T/F. In some documentation systems, the collaborative pathway is part of a
computerized documentation system that integrates the collaborative pathway and
documentation flow sheets designed to match each day's expected outcomes. correct
answers True
What part of the client's record is commonly used to document specific client variables,
such as vital signs? correct answers Graphic record/flow sheet
What is a flow sheet? correct answers Flow sheets are documentation tools used to
efficiently record routine aspects of nursing care. Well-designed flow sheets enable
nurses to quickly document the routine aspects of care that promote patient goal
achievement, safety, and well-being.
What is a graphic record? correct answers The graphic record is a form used to record
specific patient variables such as pulse, respiratory rate, blood pressure readings, body
temperature, weight, fluid intake and output, bowel movements, and other patient
characteristics.
What are the types of Flow Sheets? correct answers Types of Flow Sheets: Graphic
record, 24-hour fluid balance record, Medication administration record (MAR), 24-hour
patient care record, & Acuity records.
What is the primary purpose of an incident report correct answers Means of identifying
risk
