NUR 211 Exam 2
Review Questions with
100% correct answers
(latest update)
The hospital has just implemented the use of electronic health
records (EHRs). While learning how to use this new system, the
nurse realizes that EHRs may do which of the following?
a. Limit access to the patient record to one person at a time
b. Improve access to client information at the point of care
c. Negate the use of nursing documentation
d. increase the potential for medication errors - answer b
Use of EHRs can improve access to patients' information. An
unlimited number of people at a time can access a patient's medical
record. Nursing documentation is an essential part of nursing care,
whether it is completed on paper or electronically. The potential for
medication errors decreases when electronic medication
administration records are used.
Which statement best contributes to the nurse's documentation of
assessment of patient status in the patient's medical chart?
a. "patient had a good day with minimal complaints. Pt was pleasant
and cooperative during morning care."
b. "Pt complained that the nurse didn't come quickly enough when
she pressed the call button."
c. "Pt complained of pain 7 of 10 at 7:45 am. Received pain med at
8am, reporting pain 3 of 10 at 8:30am"
,d. "Pt was grumpy today, even after administration of pain
medication, a back massage, and a nap" - answer c
This entry is concise, complete, and objective. It gives exact times,
pain levels, and nursing interventions performed. Using terms like
good or grumpy are subjective judgments or opinions and should be
avoided. Stating a patient complaint would be okay if it listed
specific times of occurrence, nursing assessment performed, and
the nursing interventions performed to correct the issue.
A patient requests a copy of his medical record. What is the correct
response by the nurse?
a. Inform him that his record is the property of the facility and
cannot be accessed by anyone but staff.
b. Tell him that the Code for Nurses does not allow you to give him
access to his records.
c. Acknowledge that he has the right to have a copy of his records,
and make arrangements per facility policy.
d. Refer his request to the hospital administrator since all such
requests need to go through proper channels - answer c
As part of the Health Insurance Portability and Accountability Act
(HIPAA) of 1996, and updated in 2009 in The American Recovery and
Reinvestment Act (ARRA), patients' rights include obtaining,
viewing, or updating a copy of their own medical records. Usually an
EHR copy is sent to the patient within 30 days. Facilities can charge
the patient for the cost incurred in copying and sending medical
records. Methods for implementation vary by facility and type of
medical record. The Code for Nurses does not control who has
access to medical records. Requests would go through the medical
records department, or whoever is responsible for obtaining and
copying patient records.
A patient's sister comes to visit and asks to read the patient's chart.
What is the best response by the nurse?
a. Settle her in a chair at the nurses' station and give her the chart.
b. Respond that the contents of a patient's chart are private and
confidential.
,c. Tell her she can read the chart only if the patient sits with her.
d. Distract the sister by changing the subject and then walking
away. - answer b
Without special permission from the patient, only those with a need-
to-know-the-information-for-care reasons have access to the
medical record. The patient has a legal right to control access to
personal information, and the nurse should not give the sister the
chart for review, even with the patient present. It is best to be
honest and explain the patient's legal rights rather than avoiding
the subject.
Which are reasons that accurate documentation in the medical
record is important? (select all that apply)
a. remimbursement for care
b. evidence of care provided
c. communication between health care providers
d. nonlegal documentation of a nurse's actions
e. promotion of continuity of care - answer a, b, c, e
Documentation in the medical record is important for
reimbursement for care, for providing a record of services, for
communication between providers, and for promoting continuity of
care. The record is a legal document, not a non-legal document.
Which note is an example of the S in SBAR?
a. Patient resting; pain was rated 3 of 10 1 hour after receiving
narcotic analgesic.
b. Patient was admitted on evening shift with a fractured right
femur after a fall at home.
c. Patient's pain was rated 8 of 10 before administration of narcotic
pain medication.
d. Assess pain ever 2 hours, continue pain medication as prescribed,
and provide backrub. - answer a
, The S in SBAR stands for situation. In this case, the patient is
resting, and the pain is rated 3 of 10 one hour after receiving a
narcotic analgesic. Describing the admission reason and time
provides the background (B). Assessment (A) of this patient
revealed pain rated 8 of 10 before giving pain medication. The
nurse's recommendation (R) is that pain should be assessed every 2
hours and that pain medications should be given as prescribed.
Which attributes are important in nursing documentation? (select all
that apply)
a. Inconsequentiality
b. Timeliness
c. Relevancy
d. Accuracy
e. Factual basis - answer b, c, d, e.
Documentation should be completed in a timely manner, be relevant
and concise, and be accurate and factual. Inconsequentiality
suggests a lack of importance, and documentation is an important
part of patient care and nursing responsibility
When should administered medications be documented?
a. At the end of a shift when all meds have been given
b. As given to avoid the possibility of double dosing
c. After every meal to document at least three times daily
d. In pencil to allow for changes to be made - answer b
All medications and nursing care should be documented as it is
completed to ensure that documentation occurs in a timely manner.
Documentation should occur as soon as possible after assessment,
interventions (including medication administration), condition
changes, or evaluation. Documentation only at the end of a shift or
after meals would not be timely and could lead to medication errors
and fragmented care. Nursing documentation is a legal record and
is done electronically or in ink so that it cannot be changed. Errors
are corrected in a specific way depending on the type of charting,
but the original documentation would still be accessible.
Review Questions with
100% correct answers
(latest update)
The hospital has just implemented the use of electronic health
records (EHRs). While learning how to use this new system, the
nurse realizes that EHRs may do which of the following?
a. Limit access to the patient record to one person at a time
b. Improve access to client information at the point of care
c. Negate the use of nursing documentation
d. increase the potential for medication errors - answer b
Use of EHRs can improve access to patients' information. An
unlimited number of people at a time can access a patient's medical
record. Nursing documentation is an essential part of nursing care,
whether it is completed on paper or electronically. The potential for
medication errors decreases when electronic medication
administration records are used.
Which statement best contributes to the nurse's documentation of
assessment of patient status in the patient's medical chart?
a. "patient had a good day with minimal complaints. Pt was pleasant
and cooperative during morning care."
b. "Pt complained that the nurse didn't come quickly enough when
she pressed the call button."
c. "Pt complained of pain 7 of 10 at 7:45 am. Received pain med at
8am, reporting pain 3 of 10 at 8:30am"
,d. "Pt was grumpy today, even after administration of pain
medication, a back massage, and a nap" - answer c
This entry is concise, complete, and objective. It gives exact times,
pain levels, and nursing interventions performed. Using terms like
good or grumpy are subjective judgments or opinions and should be
avoided. Stating a patient complaint would be okay if it listed
specific times of occurrence, nursing assessment performed, and
the nursing interventions performed to correct the issue.
A patient requests a copy of his medical record. What is the correct
response by the nurse?
a. Inform him that his record is the property of the facility and
cannot be accessed by anyone but staff.
b. Tell him that the Code for Nurses does not allow you to give him
access to his records.
c. Acknowledge that he has the right to have a copy of his records,
and make arrangements per facility policy.
d. Refer his request to the hospital administrator since all such
requests need to go through proper channels - answer c
As part of the Health Insurance Portability and Accountability Act
(HIPAA) of 1996, and updated in 2009 in The American Recovery and
Reinvestment Act (ARRA), patients' rights include obtaining,
viewing, or updating a copy of their own medical records. Usually an
EHR copy is sent to the patient within 30 days. Facilities can charge
the patient for the cost incurred in copying and sending medical
records. Methods for implementation vary by facility and type of
medical record. The Code for Nurses does not control who has
access to medical records. Requests would go through the medical
records department, or whoever is responsible for obtaining and
copying patient records.
A patient's sister comes to visit and asks to read the patient's chart.
What is the best response by the nurse?
a. Settle her in a chair at the nurses' station and give her the chart.
b. Respond that the contents of a patient's chart are private and
confidential.
,c. Tell her she can read the chart only if the patient sits with her.
d. Distract the sister by changing the subject and then walking
away. - answer b
Without special permission from the patient, only those with a need-
to-know-the-information-for-care reasons have access to the
medical record. The patient has a legal right to control access to
personal information, and the nurse should not give the sister the
chart for review, even with the patient present. It is best to be
honest and explain the patient's legal rights rather than avoiding
the subject.
Which are reasons that accurate documentation in the medical
record is important? (select all that apply)
a. remimbursement for care
b. evidence of care provided
c. communication between health care providers
d. nonlegal documentation of a nurse's actions
e. promotion of continuity of care - answer a, b, c, e
Documentation in the medical record is important for
reimbursement for care, for providing a record of services, for
communication between providers, and for promoting continuity of
care. The record is a legal document, not a non-legal document.
Which note is an example of the S in SBAR?
a. Patient resting; pain was rated 3 of 10 1 hour after receiving
narcotic analgesic.
b. Patient was admitted on evening shift with a fractured right
femur after a fall at home.
c. Patient's pain was rated 8 of 10 before administration of narcotic
pain medication.
d. Assess pain ever 2 hours, continue pain medication as prescribed,
and provide backrub. - answer a
, The S in SBAR stands for situation. In this case, the patient is
resting, and the pain is rated 3 of 10 one hour after receiving a
narcotic analgesic. Describing the admission reason and time
provides the background (B). Assessment (A) of this patient
revealed pain rated 8 of 10 before giving pain medication. The
nurse's recommendation (R) is that pain should be assessed every 2
hours and that pain medications should be given as prescribed.
Which attributes are important in nursing documentation? (select all
that apply)
a. Inconsequentiality
b. Timeliness
c. Relevancy
d. Accuracy
e. Factual basis - answer b, c, d, e.
Documentation should be completed in a timely manner, be relevant
and concise, and be accurate and factual. Inconsequentiality
suggests a lack of importance, and documentation is an important
part of patient care and nursing responsibility
When should administered medications be documented?
a. At the end of a shift when all meds have been given
b. As given to avoid the possibility of double dosing
c. After every meal to document at least three times daily
d. In pencil to allow for changes to be made - answer b
All medications and nursing care should be documented as it is
completed to ensure that documentation occurs in a timely manner.
Documentation should occur as soon as possible after assessment,
interventions (including medication administration), condition
changes, or evaluation. Documentation only at the end of a shift or
after meals would not be timely and could lead to medication errors
and fragmented care. Nursing documentation is a legal record and
is done electronically or in ink so that it cannot be changed. Errors
are corrected in a specific way depending on the type of charting,
but the original documentation would still be accessible.
