DOCUMENTING, REPORTING, CONFERRING
FUNDAMENTALS Q & A
1.What is the nurse's best defense if a patient alleges nursing negligence?
A) testimony of other nurses
B) testimony of expert witnesses
C) patient's record
D) patient's family
2.A nurse is documenting the intensity of a patient's pain. What would be the most accurate
entry?
A) “Patient complaining of severe pain.”
B) “Patient appears to be in a lot of pain and is crying.”
C) “Patient states has pain; walking in hall with ease.”
D) “Patient states pain is a 9 on a scale of 1 to 10.”
3. Which of the following data entries follows the recommended guidelines for
documenting data?
A) “Patient is overwhelmed by the diagnosis of pancreatic cancer.”
B) “Patient kidneys are producing sufficient amount of measured urine.”
C) “Following oxygen administration, vital signs returned to baseline.”
D) “Patient complained about the quality of the nursing care provided on
previous shift.”
4. Alice Jones, a registered nurse, is documenting assessments at the beginning of her
shift. How should she sign the entry?
, DOCUMENTING, REPORTING, CONFERRING
FUNDAMENTALS Q & A
A) Alice J, RN
B) A. Jones, RN
C) Alice Jones
D) AJRN
5. In which of the following cases should a progress note be written? Select all that apply.
A) for any nurse–patient interaction
B) when admitting a patient
C) when receiving a patient postoperatively
D) when assisting a patient with ADLs
E) when a procedure is performed
F) when a patient sends back an untouched dinner tray
6.A student has reviewed a patient's chart before beginning assigned care. Which of the
following actions violates patient confidentiality?
A) writing the patient's name on the student care plan
B) providing the instructor with plans for care
C) discussing the medications with a unit nurse
FUNDAMENTALS Q & A
1.What is the nurse's best defense if a patient alleges nursing negligence?
A) testimony of other nurses
B) testimony of expert witnesses
C) patient's record
D) patient's family
2.A nurse is documenting the intensity of a patient's pain. What would be the most accurate
entry?
A) “Patient complaining of severe pain.”
B) “Patient appears to be in a lot of pain and is crying.”
C) “Patient states has pain; walking in hall with ease.”
D) “Patient states pain is a 9 on a scale of 1 to 10.”
3. Which of the following data entries follows the recommended guidelines for
documenting data?
A) “Patient is overwhelmed by the diagnosis of pancreatic cancer.”
B) “Patient kidneys are producing sufficient amount of measured urine.”
C) “Following oxygen administration, vital signs returned to baseline.”
D) “Patient complained about the quality of the nursing care provided on
previous shift.”
4. Alice Jones, a registered nurse, is documenting assessments at the beginning of her
shift. How should she sign the entry?
, DOCUMENTING, REPORTING, CONFERRING
FUNDAMENTALS Q & A
A) Alice J, RN
B) A. Jones, RN
C) Alice Jones
D) AJRN
5. In which of the following cases should a progress note be written? Select all that apply.
A) for any nurse–patient interaction
B) when admitting a patient
C) when receiving a patient postoperatively
D) when assisting a patient with ADLs
E) when a procedure is performed
F) when a patient sends back an untouched dinner tray
6.A student has reviewed a patient's chart before beginning assigned care. Which of the
following actions violates patient confidentiality?
A) writing the patient's name on the student care plan
B) providing the instructor with plans for care
C) discussing the medications with a unit nurse
