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NUR 100 Chapter 26 Exam Questions with Correct Answers
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NUR 100 Chapter 26 Exam Questions with Correct Answers
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NUR 100 Chapter 26 Exam Questionswith Correct Answers
1. A nurse preceptor is working with a student nurse. Which behavior by the student
nurse will
require the nurse preceptor to intervene?
a. The student nurse reads the patient's plan of care.
b. The student nurse reviews the patient's medical record.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient. - Answer-ANS:
C
When you are a student in a clinical setting, confidentiality and compliance with the
Health Insurance
Portability and Accountability Act (HIPAA) are part of professional practice. When a
student nurse
shares patient information with a friend, confidentiality and HIPAA standards have been
violated,
causing the preceptor to intervene. You can review your patients' medical records only
to seek
information needed to provide safe and effective patient care. For example, when you
are assigned
to care for a patient, you need to review the patient's medical record and plan of care.
You do
not share this information with classmates and you do not access the medical records of
other
patients on the unit.
2. A nurse exchanges information with the oncoming nurse about a patient's care.
Which action did
the nurse complete?
a. A verbal report
b. An electronic record entry
c. A referral
d. An acuity rating - Answer-ANS: A
Whether the transfer of patient information occurs through verbal reports, electronic or
written
documents, you need to follow some basic principles. Reports are exchanges of
information among
caregivers. A patient's electronic medical record or chart is a confidential, permanent
legal
documentation of information relevant to a patient's health care. Nurses document
referrals
,(arrangements for the services of another care provider). Nurses use acuity ratings to
determine the
hours of care and number of staff required for a given group of patients every shift or
every 24 hours.
3. A nurse is auditing and monitoring patients' health records. Which action is the nurse
taking?
a. Determining the degree to which standards of care are met by reviewing patients'
health records
b. Realizing that care not documented in patients' health records still qualifies as care
provided
c. Basing reimbursement upon the diagnosis-related groups documented in patients'
records
d. Comparing data in patients' records to determine whether a new treatment had better
outcomes than the standard treatment - Answer-ANS: A
The auditing and monitoring of patients' health records involve nurses periodically
auditing records
to determine the degree to which standards of care are met and identifying areas
needing
improvement and staff development. The mistakes in documentation that commonly
result in
malpractice include failing to record nursing actions; this is the aspect of legal
documentation. The
financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as
the basis for
establishing reimbursement for patient care. For research purposes, the researcher
compares the
patient's recorded findings to determine whether the new method was more effective
than the
standard protocol. Data analysis contributes to evidence-based nursing practice and
quality health
care.
4. After providing care, a nurse charts in the patient's record. Which entry will the nurse
document?
a. Appears restless when sitting in the chair
b. Drank adequate amounts of water
c. Apparently is asleep with eyes closed
d. Skin pale and cool - Answer-ANS: D
A factual record contains descriptive, objective information about what a nurse
observes, hears,
palpates, and smells. Objective data is obtained through direct observation and
measurement (skin
pale and cool). For example, "B/P 80/50, patient diaphoretic, heart rate 102 and
regular." Avoid
, vague terms such as appears, seems, or apparently because these words suggest that
you are
stating an opinion, do not accurately communicate facts, and do not inform another
caregiver of
details regarding behaviors exhibited by the patient. Use of exact measurements
establishes
accuracy. For example, a description such as "Intake, 360 mL of water" is more
accurate than
"Patient drank an adequate amount of fluid."
5. A nurse has provided care to a patient. Which entry should the nurse document in the
patient's
record?
a. Status unchanged, doing well
b. Patient seems to be in pain and states, "I feel uncomfortable."
c. Left knee incision 1 inch in length without redness, drainage, or edema
d. Patient is hard to care for and refuses all treatments and medications. Family is
present. - Answer-ANS: C
Use of exact measurements establishes accuracy. Charting that an abdominal wound is
"approximated, 5 cm in length without redness, drainage, or edema," is more descriptive
than "large
abdominal incision healing well." Include objective data to support subjective data, so
your charting
is as descriptive as possible. Avoid using generalized, empty phrases such as "status
unchanged" or
"had good day." It is essential to avoid the use of unnecessary words and irrelevant
details or
personal opinions. "Patient is hard to care for" is a personal opinion and should be
avoided. It is also
a critical comment that can be used as evidence for nonprofessional behavior or poor
quality of care.
Just chart, "Refuses all treatments and medications."
6. A preceptor is working with a new nurse on documentation. Which situation will cause
the
preceptor to follow up?
a. The new nurse documents only for self.
b. The new nurse charts consecutively on every other line.
c. The new nurse ends each entry with signature and title.
d. The new nurse keeps the password secure. - Answer-ANS: B
Chart consecutively, line by line (not every other line); every other line is incorrect and
must be
corrected by the preceptor. If space is left, draw a line horizontally through it, and place
your
signature and credentials at the end. Every other line should not be left blank. All the
other behaviors
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