NUR 315 Foundations of Nursing Exam 1 with complete solution
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NUR 315 Foundations of Nursing Exam 1
with complete solutions
A manager is reviewing the nursing documentation entered by a staff nurse in a
patient's electronic medical record and finds the following entry, "Patient is
difficult to care for, refuses suggestion for improving appetite." Which of the
following statements is most appropriate for the manager to make to the staff
nurse who entered this information?
1. "Avoid rushing when documenting an entry in the medical record."
2. "Use correction fluid to remove the entry."
3. "Draw a single line through the statement and initial it."
4. Enter only objective and factual information about a patient in the medical
record. - ANSWER- 4. Enter only objective and factual information about patient
in the medical record.
A preceptor observes a new graduate nurse discussing changes in a patient's
condition with a physician over the phone. The new graduate nurse accepts
telephone orders for a new medication and for some laboratory tests form the
physician at the end of the conversation. During the conversation the new
graduate writes the orders down on a piece of paper to enter them into the
electronic medical record when computer terminal is available. At this hospital
new medication orders entered into the electronic medical record can be viewed
immediately by hospital pharmacists, and hospital policy states that all new
medications must be reviewed by a pharmacist before being administered to
patients. Which of the following actions requires the preceptor to intervene? The
new nurse:
1. Reads the orders back to the health care provider to verify accuracy of
transcribing the orders after receiving them over the phone.
2. Documents th - ANSWER- 3. Gives a newly ordered medication before entered
the order in the patient's medical record.
,As the nurse enters a patient's room, the nurse notices that the patient is
anxious. The patient quickly states, "I don't know what's going on; I can't get an
explanation from my doctor about my test results. I want something done about
this." Which of the following is the most appropriate way for the nurse to
document this observation of the patient?
1. "The patient has a defiant attitude and is demanding test results."
2. "The patient appears to be upset with the nurse because he wants his test
results immediately."
3. "The patient is demanding and is complaining about the doctor."
4. "The patient stated feelings of frustration from the lack of information received
regarding test results." - ANSWER- 4. "The patient stated feelings of frustration
from the lack of information received regarding test results."
The nurse is reviewing the Health Insurance Portability and Accountability Act
(HIPAA) regulations with the patient during the admission process. The patient
states, "I'm not familiar with these HIPAA regulations. How will they affect my
care?" Which of the following is the best response
1. HIPAA allows all hospital staff access to your medical record.
2. HIPAA limits the information that is documented in your medical record.
3. HIPAA provides you with greater protection of your personal health
information.
4. HIPAA enables health care institutions to release all of your personal
information to improve continuity of care. - ANSWER- 3. HIPAA provides you with
greater protection of your personal health information.
A patient states, "I would like to see what is written in my medical record." What
is the nurse's best response?
1. "Only your family can read your medical record."
2. "You have the right to read your record."
3. "Patients are not allowed to read their records."
4. "Only health care workers have access to patient records." - ANSWER- 2. "You
have the right to read your record."
Which of the following documentation entries is most accurate?
1. "Patient walked up and down hallway with assistance, tolerated well."
2. "Patient up, out of bed, walked down hallway and back to room, tolerated well."
3. "Patient up, walked 50 feet and back down hallway with assistance from nurse.
Spouse also accompanied patient during the walk."
4. "Patient walked 50 feet and back down hallway with assistance from nurse; HR
88 and regular before exercise, HR 94 and regular following exercise." - ANSWER-
, 4. "Patient walked 50 feet and back down hallway with assistance from nurse; HR
88 and regular before exercise, HR 94 and regular following exercise."
Label each line of documentation with the appropriate SOAP category (Subjective
[S], Objective [O], Assessment [A], Plan [P]).
1. ______ Repositioned patient on right side. Encouraged patient to use patient-
controlled analgesia (PCA) device.
2. ______ "The pain increases every time I try to turn on my left side."
3. ______ Acute pain related to tissue injury from surgical incision.
4. ______ Left lower abdominal surgical incision, 3 inches in length, closed,
sutures intact, no drainage. Pain noted on mild palpation. - ANSWER- 1. Plan
2. Subjective
3. Assessment
4. Objective
Fill in the Blank. While working on a unit within a hospital, the nurse was able to
access a patient's medical record and review the education that other nurses
provided during an initial hospitalization and three subsequent clinic visits that
occurred in different provider's offices over the past 6 months. This type of
feature is most common in a(n) __________________________. - ANSWER-
Electronic health record
The nurse is transferring a patient to a long-term, skilled care facility and has just
given a telephone report to a registered nurse (RN) who works at that facility and
who will be receiving the patient. In documenting this call, the nurse begins by
writing the date and time the report was given and the name of the RN taking the
report. Which of the following pieces of information does the nurse include in the
documentation of this telephone call? (Select all that apply.)
1. The patient's name, age, and admitting diagnoses
2. The discussion of any allergies to food and medications that the patient has
3. That the nurse receiving the report was advised that the patient is "needy" and
"on the call light all the time"
4. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after
receiving 650 mg of Tylenol
5. Description of any unresolved problems and current interventions in place -
ANSWER- 1. The patient's name, age, and admitting diagnoses
2. The discussion of any allergies to food and medications that the patient has
4. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after
receiving 650 mg of Tylenol
5. Description of any unresolved problems and current interventions in place
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