Questions 2026 Exam All
Answers and Illustrations
Given
Why must documentation be precise and thorough? - ANSWER
✔✔Accurate documentation provides a clear record of care to support
continuity and patient safety.
What is necessary for hospitals to be reimbursed by Medicare or
Medicaid? - ANSWER ✔✔Accurate documentation according to
diagnostic-related groups (DRGs).
,What reflects high-quality nursing documentation? - ANSWER
✔✔High-quality nursing documentation reflects the nursing process.
What is the role of the medical record? - ANSWER ✔✔It serves as a
major communication tool and is a legal document.
Why are paper records being replaced by electronic health records
(EHRs)? - ANSWER ✔✔Paper records are fragile and susceptible to
damage.
What should a nurse do when charting in a paper medical record? -
ANSWER ✔✔Use black ink unless the facility allows a different color.
Which document provides a longitudinal record of health? - ANSWER
✔✔Electronic health record (EHR).
What is a true statement about electronic health records? - ANSWER
✔✔They improve the overall patient's health status.
How can a nurse protect personal health information in EHRs? -
ANSWER ✔✔The nurse should never share their password with
anyone, even a trusted colleague.
What should nursing documentation include? - ANSWER ✔✔Facts
and subjective data from the patient.
,What is the nursing process that guides documentation? - ANSWER
✔✔Assessment, diagnosis, planning, implementation, and evaluation.
What do the documentation methods PIE, APIE, SOAP, and SOAPIE
have in common? - ANSWER ✔✔They are examples of problem-
oriented charting.
What type of charting records only abnormal or significant data? -
ANSWER ✔✔Charting by exception (CBE).
What document should a nurse compare provider orders with before
administering medications? - ANSWER ✔✔Medication administration
record (MAR).
What is the best source for a nurse to obtain a patient's history and
medications taken at home? - ANSWER ✔✔Admission summary.
What is a key fact about paper nursing notes? - ANSWER ✔✔A
medical record is the most reliable source of information in a legal
action.
What identifies the person charting in electronic documentation? -
ANSWER ✔✔Log-on access to the electronic record.
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3
, What action should a nurse take to correct an error in paper charting? -
ANSWER ✔✔Draw a single line through the error and write 'error'
above or after the entry, along with the nurse's initials.
What action must be taken when a verbal or phone order is necessary in
an emergency? - ANSWER ✔✔The order must be taken by an RN or
LPN, repeated verbatim to confirm accuracy, and documented as a
written order.
What is the importance of hand-off reporting in nursing? - ANSWER
✔✔Hand-off reporting provides accurate, timely information to ensure
patient safety and can lead to collaborative problem solving.
What should a nurse do after a patient falls while attempting to climb out
of bed? - ANSWER ✔✔Complete an incident report as a risk
management document.
What components of the patient's medical record should the nurse
document? - ANSWER ✔✔Nursing assessment, the care plan, and
interventions.
Which abbreviations are considered unacceptable by The Joint
Commission? - ANSWER ✔✔QD, Qod, and IU.