RNSG 1513 Foundations of Nursing Exam 2 (2026) UPDATE
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Terms in this set (284)
A manager who is reviewing the nurses' notes in a D) Enter only objective and factual information about the patient.
patient's medical record finds the following entry, "Patient
is difficult to care for, refuses suggestion for improving
appetite." Which of the following directions does the Nurses should enter only objective and factual information about patients.
manager give to the staff nurse who entered the note? Opinions have no place in the medical record. Because the information has
A) Avoid rushing when charting an entry. already been entered and is not incorrect, it should be left on the record. Never
B) Use correction fluid to remove the entry. use correction fluid in a written medical record.
C) Draw a single line through the statement and initial it.
D) Enter only objective and factual information about the
patient.
A new graduate nurse is providing a telephone report to B) Gives a newly ordered medication before entering the order in the patient's
a patient's health care provider and accepting telephone medical record.
orders from the provider. Which of the following actions
requires the new nurse's preceptor to intervene? The new Nurses enter orders into the computer or write them on the order sheet as they
nurse: are being given to allow the read-back process to occur.
A) Uses SBAR (Situation-Background-Assessment-
Recommendation) as a format when providing the report.
B) Gives a newly ordered medication before entering the
order in the patient's medical record.
C) Reads the orders back to the health care provider
after receiving them and verifies their accuracy.
D) Asks the preceptor to listen in on the phone
conversation.
,As you enter the patient's room, you notice that he is D. The patient stated that he felt frustrated by the lack of information he received
anxious to say something. He quickly states, "I don't know regarding his tests.
what's going on; I can't get an explanation from my This is a nonjudgmental statement regarding the nurse's observations about the
doctor about my test results. I want something done patient. Documenting that the patient had a defiant attitude or was demanding
about this." Which of the following is the most and frequently complaining is judgmental, and information in the medical record
appropriate documentation of the patient's emotional should be factual and nonjudgmental. Documenting that the patient appears
status? upset needs to be more specific regarding the reason for the patient's concern.
A. The patient has a defiant attitude and is demanding his
test results.
B. The patient appears to be upset with his nurse because
he wants his test results immediately.
C. The patient is demanding and complains frequently
about his doctor.
D. The patient stated that he felt frustrated by the lack of
information he received regarding his tests.
You are reviewing Health Insurance Portability and C. HIPAA provides you with greater control over your personal health care
Accountability Act (HIPAA) regulations with your patient information.
during the admission process. The patient states, "I've
heard a lot about these HIPAA regulations in the news
lately. How will they affect my care?" Which of the HIPAA provides patients with control over who receives and accesses their
following is the best response? medical records. It does not allow uncontrolled access to the medical records.
A. HIPAA allows all hospital staff access to your medical HIPAA also does not dictate what must be documented in the patient's medical
record. record.
B. HIPAA limits the information that is documented in your
medical record.
C. HIPAA provides you with greater control over your
personal health care information.
D. HIPAA enables health care institutions to release all of
your personal information to improve continuity of care.
A patient asks for a copy of her medical record. The best B. Indicate that she has the right to read her record.
response by the nurse is to:
A. State that only her family may read the record.
B. Indicate that she has the right to read her record. Patients have the right to read their medical records, but the nurse should always
C. Tell her that she is not allowed to read her record. know the facility policy regarding personal access to medical records because
D. Explain that only health care workers have access to some require a nurse manager or other official to be present to answer questions
her record. about what is in the record. Families may read the records only when the patient
has given permission.
Which of the following charting entries is most accurate? D. Patient walked 50 feet and back down hallway with assistance from nurse; HR
A.Patient walked up and down hallway with assistance, 88 and regular before exercise, 94 and regular following exercise.
tolerated well.
B. Patient up, out of bed, walked down hallway and back The statement "Patient walked 50 feet and back down hallway with assistance
to room, tolerated well. from nurse; HR 88 and regular before exercise, 94 and regular following exercise"
C. Patient up, walked 50 feet and back down hallway with provides the most accurate, objective information for the chart.
assistance from nurse. Spouse also accompanied patient
during the walk.
D. Patient walked 50 feet and back down hallway with
assistance from nurse; HR 88 and regular before exercise,
94 and regular following exercise.
,Match the correct entry with the appropriate SOAP S-2
(Subjective—Objective—Assessment—Plan) category. O-4
S A-3
O P-1
A
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.
On the nursing unit you are able to access a patient's B. Electronic health record.
medical record and review the education that other
nurses provided to the patient during an initial
hospitalization and three subsequent clinic visits. This This is an example of an electronic health record. The electronic health record is
type of feature is most common in what type of record an electronic record of patient health information generated whenever a patient
system? accesses medical care in any health care delivery setting. In this question you are
A. Information technology. able to access information about the patient from the current hospitalization and
B. Electronic health record. from four previous times when the patient accessed care.
C. Personal health information.
D. Administrative information system.
You are giving a hand-off report to another nurse who A. The patient's name, age, and admitting diagnosis
will be caring for your patient at the end of your shift. B. Allergies to food and medications
Which of the following pieces of information do you E. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after
include in the report? (Select all that apply.) receiving 650 mg of Tylenol
A. The patient's name, age, and admitting diagnosis
B. Allergies to food and medications During change of shift report, include essential background information such as
C. Your evaluation that the patient is "needy" the patient's name, age, diagnosis, and allergies. Also include response to
D. How much the patient ate for breakfast treatments such as response to pain-relieving measures. Information about how
E. That the patient's pain rating went from 8 to 2 on a much the patient ate for breakfast is not necessary. This information is in the chart
scale of 1 to 10 after receiving 650 mg of Tylenol if the nurse really needs to know. Do not include critical comments about your
patients.
You are supervising a beginning nursing student who is A. Documented medication given by another nursing student.
documenting patient care. Which of the following actions
requires you to intervene? The nursing student:
A. Documented medication given by another nursing Nurses only document the care they provide; entries in the chart need to be
student. dated, timed, and signed.
B. Included the date and time of all entries in the chart.
C. Stood with his back against the wall while
documenting on the computer.
D. Signed all documentation electronically.
, A group of nurses is discussing the advantages of using A. "CPOE reduces transcription errors."
computerized provider order entry (CPOE). Which of the
following statements indicates that the nurses understand
the major advantage of using CPOE? CPOE eliminates the need for someone to transcribe the orders because it allows
A. "CPOE reduces transcription errors." the provider to enter the order directly.
B. "CPOE reduces the time necessary for health care
providers to write orders."
C. "Health care providers can write orders from any
computer that has Internet access."
D. "CPOE reduces the time nurses use to communicate
with health care providers."
You are helping to design a new patient discharge B. You need to use words the patients can understand when writing the directions.
teaching sheet that will go home with patients who are
discharged to home from your unit. Which of the
following do you need to remember when designing the Patients need to be able to understand information that you provide to them;
teaching sheet? ensure that written instructions are provided at a level that matches the patients'
A. The new federal laws require that teaching sheets be reading ability.
e-mailed to patients after they are discharged.
B. You need to use words the patients can understand
when writing the directions.
C. The form needs to be given to patients in a sealed
envelope to protect their health information.
D. The names of everyone who cared for the patient in
the hospital need to be included on the form in case the
patient has questions at home.
A nurse caring for a patient on a ventilator electronically Clinical decision support system
documents the head of bed elevated at 20 degrees.
Suddenly an alert warning appears on the screen A clinical decision support system is based on rules that are triggered by data
warning the nurse that this patient is at a high risk for entry. When certain rules are not met, alerts, warnings, or other information may
aspiration because the head of the bed is not elevated be provided to the user.
high enough. This warning is known as what type of
system?
A. Electronic health record
B. Clinical documentation
C. Clinical decision support system
D. Computerized physician order entry
While reviewing the pulmonary section of a patient's The nurses were charting by exception.
electronic chart, the physician notices blank spaces since
the initial assessment the previous day when the nurse Given that the initial assessment indicated that the pulmonary system was within
documented that the lung assessment was within normal normal limits, the facility is most likely documenting by exception. There is no
limits. There also are no progress notes about the need for further documentation unless the pulmonary assessment changes and is
patient's respiratory status in the nurse's notes. The most no longer within normal limits.
likely reason for this is because:
A. The nurses forgot to document on the pulmonary
system.
B. The nurses were charting by exception.
C. The computer is not working correctly.
D. The physician does not have authorization to view the
nursing assessment.
Verified Questions And Answers | With 100% Correct
Answers graded A+ Guaranteed Success!!
Save
Students also studied
Disaster Response & Recovery NIHSS Group C - Patients 1-6 Delivering International Health Care... NR 442
16 terms 6 terms 16 terms 65 terms
ImeldaRN Preview quizlette38033486 Preview ImeldaRN Preview Ale
Terms in this set (284)
A manager who is reviewing the nurses' notes in a D) Enter only objective and factual information about the patient.
patient's medical record finds the following entry, "Patient
is difficult to care for, refuses suggestion for improving
appetite." Which of the following directions does the Nurses should enter only objective and factual information about patients.
manager give to the staff nurse who entered the note? Opinions have no place in the medical record. Because the information has
A) Avoid rushing when charting an entry. already been entered and is not incorrect, it should be left on the record. Never
B) Use correction fluid to remove the entry. use correction fluid in a written medical record.
C) Draw a single line through the statement and initial it.
D) Enter only objective and factual information about the
patient.
A new graduate nurse is providing a telephone report to B) Gives a newly ordered medication before entering the order in the patient's
a patient's health care provider and accepting telephone medical record.
orders from the provider. Which of the following actions
requires the new nurse's preceptor to intervene? The new Nurses enter orders into the computer or write them on the order sheet as they
nurse: are being given to allow the read-back process to occur.
A) Uses SBAR (Situation-Background-Assessment-
Recommendation) as a format when providing the report.
B) Gives a newly ordered medication before entering the
order in the patient's medical record.
C) Reads the orders back to the health care provider
after receiving them and verifies their accuracy.
D) Asks the preceptor to listen in on the phone
conversation.
,As you enter the patient's room, you notice that he is D. The patient stated that he felt frustrated by the lack of information he received
anxious to say something. He quickly states, "I don't know regarding his tests.
what's going on; I can't get an explanation from my This is a nonjudgmental statement regarding the nurse's observations about the
doctor about my test results. I want something done patient. Documenting that the patient had a defiant attitude or was demanding
about this." Which of the following is the most and frequently complaining is judgmental, and information in the medical record
appropriate documentation of the patient's emotional should be factual and nonjudgmental. Documenting that the patient appears
status? upset needs to be more specific regarding the reason for the patient's concern.
A. The patient has a defiant attitude and is demanding his
test results.
B. The patient appears to be upset with his nurse because
he wants his test results immediately.
C. The patient is demanding and complains frequently
about his doctor.
D. The patient stated that he felt frustrated by the lack of
information he received regarding his tests.
You are reviewing Health Insurance Portability and C. HIPAA provides you with greater control over your personal health care
Accountability Act (HIPAA) regulations with your patient information.
during the admission process. The patient states, "I've
heard a lot about these HIPAA regulations in the news
lately. How will they affect my care?" Which of the HIPAA provides patients with control over who receives and accesses their
following is the best response? medical records. It does not allow uncontrolled access to the medical records.
A. HIPAA allows all hospital staff access to your medical HIPAA also does not dictate what must be documented in the patient's medical
record. record.
B. HIPAA limits the information that is documented in your
medical record.
C. HIPAA provides you with greater control over your
personal health care information.
D. HIPAA enables health care institutions to release all of
your personal information to improve continuity of care.
A patient asks for a copy of her medical record. The best B. Indicate that she has the right to read her record.
response by the nurse is to:
A. State that only her family may read the record.
B. Indicate that she has the right to read her record. Patients have the right to read their medical records, but the nurse should always
C. Tell her that she is not allowed to read her record. know the facility policy regarding personal access to medical records because
D. Explain that only health care workers have access to some require a nurse manager or other official to be present to answer questions
her record. about what is in the record. Families may read the records only when the patient
has given permission.
Which of the following charting entries is most accurate? D. Patient walked 50 feet and back down hallway with assistance from nurse; HR
A.Patient walked up and down hallway with assistance, 88 and regular before exercise, 94 and regular following exercise.
tolerated well.
B. Patient up, out of bed, walked down hallway and back The statement "Patient walked 50 feet and back down hallway with assistance
to room, tolerated well. from nurse; HR 88 and regular before exercise, 94 and regular following exercise"
C. Patient up, walked 50 feet and back down hallway with provides the most accurate, objective information for the chart.
assistance from nurse. Spouse also accompanied patient
during the walk.
D. Patient walked 50 feet and back down hallway with
assistance from nurse; HR 88 and regular before exercise,
94 and regular following exercise.
,Match the correct entry with the appropriate SOAP S-2
(Subjective—Objective—Assessment—Plan) category. O-4
S A-3
O P-1
A
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.
On the nursing unit you are able to access a patient's B. Electronic health record.
medical record and review the education that other
nurses provided to the patient during an initial
hospitalization and three subsequent clinic visits. This This is an example of an electronic health record. The electronic health record is
type of feature is most common in what type of record an electronic record of patient health information generated whenever a patient
system? accesses medical care in any health care delivery setting. In this question you are
A. Information technology. able to access information about the patient from the current hospitalization and
B. Electronic health record. from four previous times when the patient accessed care.
C. Personal health information.
D. Administrative information system.
You are giving a hand-off report to another nurse who A. The patient's name, age, and admitting diagnosis
will be caring for your patient at the end of your shift. B. Allergies to food and medications
Which of the following pieces of information do you E. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after
include in the report? (Select all that apply.) receiving 650 mg of Tylenol
A. The patient's name, age, and admitting diagnosis
B. Allergies to food and medications During change of shift report, include essential background information such as
C. Your evaluation that the patient is "needy" the patient's name, age, diagnosis, and allergies. Also include response to
D. How much the patient ate for breakfast treatments such as response to pain-relieving measures. Information about how
E. That the patient's pain rating went from 8 to 2 on a much the patient ate for breakfast is not necessary. This information is in the chart
scale of 1 to 10 after receiving 650 mg of Tylenol if the nurse really needs to know. Do not include critical comments about your
patients.
You are supervising a beginning nursing student who is A. Documented medication given by another nursing student.
documenting patient care. Which of the following actions
requires you to intervene? The nursing student:
A. Documented medication given by another nursing Nurses only document the care they provide; entries in the chart need to be
student. dated, timed, and signed.
B. Included the date and time of all entries in the chart.
C. Stood with his back against the wall while
documenting on the computer.
D. Signed all documentation electronically.
, A group of nurses is discussing the advantages of using A. "CPOE reduces transcription errors."
computerized provider order entry (CPOE). Which of the
following statements indicates that the nurses understand
the major advantage of using CPOE? CPOE eliminates the need for someone to transcribe the orders because it allows
A. "CPOE reduces transcription errors." the provider to enter the order directly.
B. "CPOE reduces the time necessary for health care
providers to write orders."
C. "Health care providers can write orders from any
computer that has Internet access."
D. "CPOE reduces the time nurses use to communicate
with health care providers."
You are helping to design a new patient discharge B. You need to use words the patients can understand when writing the directions.
teaching sheet that will go home with patients who are
discharged to home from your unit. Which of the
following do you need to remember when designing the Patients need to be able to understand information that you provide to them;
teaching sheet? ensure that written instructions are provided at a level that matches the patients'
A. The new federal laws require that teaching sheets be reading ability.
e-mailed to patients after they are discharged.
B. You need to use words the patients can understand
when writing the directions.
C. The form needs to be given to patients in a sealed
envelope to protect their health information.
D. The names of everyone who cared for the patient in
the hospital need to be included on the form in case the
patient has questions at home.
A nurse caring for a patient on a ventilator electronically Clinical decision support system
documents the head of bed elevated at 20 degrees.
Suddenly an alert warning appears on the screen A clinical decision support system is based on rules that are triggered by data
warning the nurse that this patient is at a high risk for entry. When certain rules are not met, alerts, warnings, or other information may
aspiration because the head of the bed is not elevated be provided to the user.
high enough. This warning is known as what type of
system?
A. Electronic health record
B. Clinical documentation
C. Clinical decision support system
D. Computerized physician order entry
While reviewing the pulmonary section of a patient's The nurses were charting by exception.
electronic chart, the physician notices blank spaces since
the initial assessment the previous day when the nurse Given that the initial assessment indicated that the pulmonary system was within
documented that the lung assessment was within normal normal limits, the facility is most likely documenting by exception. There is no
limits. There also are no progress notes about the need for further documentation unless the pulmonary assessment changes and is
patient's respiratory status in the nurse's notes. The most no longer within normal limits.
likely reason for this is because:
A. The nurses forgot to document on the pulmonary
system.
B. The nurses were charting by exception.
C. The computer is not working correctly.
D. The physician does not have authorization to view the
nursing assessment.
