Adult Nursing Exam 1 UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS
What information is confidential in a healthcare setting? - CORRECT ANSWER All
information about patients regardless of if it is handwritten, saved on a computer, or spoken
out loud.
Give a few examples of breaches of confidentiality - CORRECT ANSWER -
Discussing patient information where it can be overheard
-Leaving patient medical information in a public area
-Leaving patient information up on a computer that is unattended
-Sharing or exposing passwords
-Improperly accessing, releasing or reviewing a patient's record out of curiosity or concern
-Improperly accessing, releasing, or reviewing any patient information regardless of your
relationship with the patient
Information/Documentation should be clear, complete, concise, accurate, and factual. What
are other important aspects of Documentation? - CORRECT ANSWER -
Documentation should reflect the nursing process and your professional responsibilities
-Avoid generalizations in documentation
-Note problems/situations in chronological order, add/update and delete problems as needed
-Record precautions or preventative measures used
-Avoid stereotypes
-Document the nursing response to questionable orders or treatment
PIE Charting - CORRECT ANSWER method of recording the client's progress under
the headings of problem, intervention, and evaluation
Focus charting - CORRECT ANSWER Brings the focus of care back to the patient and
the patient's concerns. Narrative portion uses DAR (Data, Action, Response) format
,Charting by exception - CORRECT ANSWER only documenting abnormal
findings/issues
-everything is normal except for...
SOAP format - CORRECT ANSWER method of charting narrative progress notes;
organizes data according to subjective information (S), objective information (O), assessment
(A), and plan (P)
Narrative notes - CORRECT ANSWER address routine care, normal findings, and
patient problems identified in the plan of care
ISBAR - CORRECT ANSWER Introduction
Situation
Background
Assessment
Recommendation
SOAPIE - CORRECT ANSWER subjective
Objective
Assessment
Plan
Intervention
Evaluation
Change of shift report - CORRECT ANSWER Includes:
-Basic information about each patient (name, room, bed, diagnosis, consulting physicians)
-Current appraisal of each patient's health status
-Current orders
-Abnormal occurrences during shift
-Any unfilled orders that need to be continued onto next shift
, -Patient's questions, concerns, needs
-Reports on transfers/discharge
Bedside report - CORRECT ANSWER Oncoming and outgoing nurse seeing the
patient together, reviewing medication records and the HCP's and nursing orders, and
establishing patient goals for the shift.
Problem oriented medical record - CORRECT ANSWER Organized according to
patient's problems rather than sources of information. Includes defined database, problem list,
care plans, and progress notes.
Progress notes - CORRECT ANSWER documentation of the progress a patient is
making towards achieving expected outcomes
Occurrence/variance charting - CORRECT ANSWER documentation when a patient
fails to meet an expected outcome
Include the unexpected event, the cause of the event, actions taken in response to the event,
and discharge planning, when appropriate; typically used for variances that affect quality,
cost, or length of stay
Purposes of patient records - CORRECT ANSWER -Communication
-Diagnostic and therapeutic orders
-Care planning
-Quality process and performance improvement
-Research; decision analysis
-Education
-Credentialing, regulation, and legislation
-Reimbursement
-Legal and historical documentation
QUESTIONS AND CORRECT ANSWERS
What information is confidential in a healthcare setting? - CORRECT ANSWER All
information about patients regardless of if it is handwritten, saved on a computer, or spoken
out loud.
Give a few examples of breaches of confidentiality - CORRECT ANSWER -
Discussing patient information where it can be overheard
-Leaving patient medical information in a public area
-Leaving patient information up on a computer that is unattended
-Sharing or exposing passwords
-Improperly accessing, releasing or reviewing a patient's record out of curiosity or concern
-Improperly accessing, releasing, or reviewing any patient information regardless of your
relationship with the patient
Information/Documentation should be clear, complete, concise, accurate, and factual. What
are other important aspects of Documentation? - CORRECT ANSWER -
Documentation should reflect the nursing process and your professional responsibilities
-Avoid generalizations in documentation
-Note problems/situations in chronological order, add/update and delete problems as needed
-Record precautions or preventative measures used
-Avoid stereotypes
-Document the nursing response to questionable orders or treatment
PIE Charting - CORRECT ANSWER method of recording the client's progress under
the headings of problem, intervention, and evaluation
Focus charting - CORRECT ANSWER Brings the focus of care back to the patient and
the patient's concerns. Narrative portion uses DAR (Data, Action, Response) format
,Charting by exception - CORRECT ANSWER only documenting abnormal
findings/issues
-everything is normal except for...
SOAP format - CORRECT ANSWER method of charting narrative progress notes;
organizes data according to subjective information (S), objective information (O), assessment
(A), and plan (P)
Narrative notes - CORRECT ANSWER address routine care, normal findings, and
patient problems identified in the plan of care
ISBAR - CORRECT ANSWER Introduction
Situation
Background
Assessment
Recommendation
SOAPIE - CORRECT ANSWER subjective
Objective
Assessment
Plan
Intervention
Evaluation
Change of shift report - CORRECT ANSWER Includes:
-Basic information about each patient (name, room, bed, diagnosis, consulting physicians)
-Current appraisal of each patient's health status
-Current orders
-Abnormal occurrences during shift
-Any unfilled orders that need to be continued onto next shift
, -Patient's questions, concerns, needs
-Reports on transfers/discharge
Bedside report - CORRECT ANSWER Oncoming and outgoing nurse seeing the
patient together, reviewing medication records and the HCP's and nursing orders, and
establishing patient goals for the shift.
Problem oriented medical record - CORRECT ANSWER Organized according to
patient's problems rather than sources of information. Includes defined database, problem list,
care plans, and progress notes.
Progress notes - CORRECT ANSWER documentation of the progress a patient is
making towards achieving expected outcomes
Occurrence/variance charting - CORRECT ANSWER documentation when a patient
fails to meet an expected outcome
Include the unexpected event, the cause of the event, actions taken in response to the event,
and discharge planning, when appropriate; typically used for variances that affect quality,
cost, or length of stay
Purposes of patient records - CORRECT ANSWER -Communication
-Diagnostic and therapeutic orders
-Care planning
-Quality process and performance improvement
-Research; decision analysis
-Education
-Credentialing, regulation, and legislation
-Reimbursement
-Legal and historical documentation
