NU136
NU 136 Galen Theory Exam 3 Questions and
Answers 2026
What are the 5 steps in the nursing process?
Assessment
Diagnosis
Planning
Implementation
Evaluation
What is the assessment portion of the nursing process used for?
data collection
what is the nursing diagnosis portion of the nursing process used for?
analyzing the data
what is the planning portion of the nursing process used for?
the steps to resolve the health problem present
what is the implementation portion of the nursing process used for?
carrying out the steps of the planning portion
what is the evaluation portion of the nursing process used for?
to assess the patients respose to the treatment
How often is the nursing care plan updated?
every 24 hours
what are the three charecteristics of an expected outcome?
realistic, attainable, and have a set timeline
Who should have access to the patients records?
only those who are directly involved in the patients care
What is source-oriented or narrative charting?
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, NU136
organized according to the source of the information
What is problem-oriented medical record charting (POMR)?
charting the focuses on the patient's status with an emphasis on the problem-solving
approach
What is problem identification, interventions, and evaluation charting (PIE)?
follows the nursing process and uses nursing diagnosises while placing the plan of care
within the nurses progress notes
What is focused charting?
focuses only on the direct health problems of the patient
What is charting by exception?
the assumption that all standards of practice are carried out and met with a normal or
expected response
What is computer-assisted charting or an electronic health record (EHR)?
a computerized comprehensive record of a patient's history and care across all
facilities and admissions
What is a computerized provider order entry (CPOE)?
an efficent and effective way for any orders put in through the system to be
automatically sent to the appropriate clinical areas for action
What is case management system charting?
organizing patient care through an episode of illness so that clinical outcomes are
achieved within an expected time frame and at a predictable cost
What do you never do when documenting on a computer?
walk away with the screen opened and unlocked
What does accuracy in documentation mean?
being specific and definite in using words or phrases that convey the meaning you
wish expressed
What is brevity in documentation?
NU136
NU 136 Galen Theory Exam 3 Questions and
Answers 2026
What are the 5 steps in the nursing process?
Assessment
Diagnosis
Planning
Implementation
Evaluation
What is the assessment portion of the nursing process used for?
data collection
what is the nursing diagnosis portion of the nursing process used for?
analyzing the data
what is the planning portion of the nursing process used for?
the steps to resolve the health problem present
what is the implementation portion of the nursing process used for?
carrying out the steps of the planning portion
what is the evaluation portion of the nursing process used for?
to assess the patients respose to the treatment
How often is the nursing care plan updated?
every 24 hours
what are the three charecteristics of an expected outcome?
realistic, attainable, and have a set timeline
Who should have access to the patients records?
only those who are directly involved in the patients care
What is source-oriented or narrative charting?
NU136
, NU136
organized according to the source of the information
What is problem-oriented medical record charting (POMR)?
charting the focuses on the patient's status with an emphasis on the problem-solving
approach
What is problem identification, interventions, and evaluation charting (PIE)?
follows the nursing process and uses nursing diagnosises while placing the plan of care
within the nurses progress notes
What is focused charting?
focuses only on the direct health problems of the patient
What is charting by exception?
the assumption that all standards of practice are carried out and met with a normal or
expected response
What is computer-assisted charting or an electronic health record (EHR)?
a computerized comprehensive record of a patient's history and care across all
facilities and admissions
What is a computerized provider order entry (CPOE)?
an efficent and effective way for any orders put in through the system to be
automatically sent to the appropriate clinical areas for action
What is case management system charting?
organizing patient care through an episode of illness so that clinical outcomes are
achieved within an expected time frame and at a predictable cost
What do you never do when documenting on a computer?
walk away with the screen opened and unlocked
What does accuracy in documentation mean?
being specific and definite in using words or phrases that convey the meaning you
wish expressed
What is brevity in documentation?
NU136
