NSG 200 Final Exam ACTUAL Questions and CORRECT Answers
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Course
NSG 200
Institution
NSG 200
NSG 200 Final Exam ACTUAL Questions
and CORRECT Answers
Purposes of medical record: - CORRECT ANSWER- communication
reimbursement
research
legal documentation
education
auditing / monitoring
Electronic health record: - CORRECT ANSWER- Systematic collection of a patient's
health care and ...
NSG 200 Final Exam ACTUAL Questions
and CORRECT Answers
Purposes of medical record: - CORRECT ANSWER- ✔✔communication
reimbursement
research
legal documentation
education
auditing / monitoring
Electronic health record: - CORRECT ANSWER- ✔✔Systematic collection of a patient's
health care and treatment in a digital format
Mistakes in documentation that commonly result in malpractice: - CORRECT ANSWER-
✔✔- failing to record pertinent health or drug information
- failing to record nursing actions
- failing to record medication administration
- failing to record drug reactions or changes in patient's conditions
- incomplete or illegible records
- failing to document discontinued medications
Disclosure of medical information is on what type of basis? - CORRECT ANSWER-
✔✔need to know
5 characteristics of quality documentation: - CORRECT ANSWER- ✔✔Factual
Accurate
Complete
Current
Organized
,What activities must be documented at the time of occurence? - CORRECT ANSWER- ✔✔-
VS
- pain assessment
- administration of meds and tx
- preparation for diagnostic tests
- change in pt status & who was notified
- admission, transfer, discharge, or death
- tx for sudden change in patient status
- response to tx or intervention
Methods of documentation: - CORRECT ANSWER- ✔✔- narrative note
- Problem oriented medical record
- SOAP note
- SOAPIE note
- PIE note
- focus charting (DAR)
Weakness of narrative note: - CORRECT ANSWER- ✔✔repetition
length
disorganization
What is the form of documentation that is organized by problem or diagnosis? - CORRECT
ANSWER- ✔✔problem - oriented medical record
How long after giving verbal orders does a provider have to sign the prescription? -
CORRECT ANSWER- ✔✔24 hours
, What are the stages of an interview? - CORRECT ANSWER- ✔✔Preparation
Introduction
Working
Termination
Therapeutic Communication Techniques - CORRECT ANSWER- ✔✔1) ACTIVE
LISTENING - Shows clients that they have your undivided attention
2) OPEN-ENDED QUESTIONS - Used initially to encourage clients to tell their story in
their own way. Ask questions in a language that a client can understand
3) CLARIFYING - Questioning clients about specific details in greater depth or directing
them toward relevant parts of the history.
4) SUMMARIZING - Validates the accuracy of the story.
Depth of light palpation: - CORRECT ANSWER- ✔✔1 cm
Depth of deep palpation: - CORRECT ANSWER- ✔✔4 cm
Why is percussion performed? - CORRECT ANSWER- ✔✔- evaluate size, borders, and
consistency of internal organs
- detect tenderness
- determine extent of fluid in body cavity
Direct percussion: - CORRECT ANSWER- ✔✔- strike finger or hand against patient's body
- evaluate adult sinus by tapping finger on sinus
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