CSN Nursing 101 Exam 4 Questions With All
Correct Answers
Purpose of Records Correct answer-Communication
Nursing Documentation
Financial Billing
Auditing/Monitoring
Legal Documentations
Nursing Documentation Correct answer-observation: document assessment findings
intervention: what action was taken to abnormal assessment?
response: did patient improve?
Common Record-Keeping Forms Correct answer-admission forms
consents
advanced directives
flow sheets/graphic records
progress notes
nursing care plans
MAR
Confidentiality Correct answer-all patient information is confidential: written, computerized,
telephone, verbal, fax
protecting patient information: hard chart, computerized records, student clinical worksheets, phone
conversations
HIPAA Correct answer-Health Insurance Portability and Accountability Act
patients have the right to see and copy record, have the right to request restrictions
health information can only be released for: treatment, payment, routine health care operations
violation: $250,000 fine and 10 years in prison
Guidelines for quality documentation Correct answer-Factual
Accurate
Complete
Current
Organized
Documenting Guidelines Correct answer-pen
date and time
no mistakes in entry: no whiteout, scribbling
Initials and error
no blank lines
signature with credentials
initial nursing assessment Correct answer-thorough and complete
provides baseline
, Common methods of recording Correct answer-narrative documentation (most common)
PIE: problem, intervention, evaluation
DAR: data, action, response
SOAP: subjective, objective, assessment, plan
SOAPIE: subjective, objective, assessment, plan, Intervention, evaluation
Charting by exception (flow sheets)
Reporting Correct answer-ISBARR: situation, background, assessment, recommendation- gather all
data before calling physician
Verbal orders: read back verified
Incident report situations Correct answer-medication errors
complications from treatment/procedure
failure to report change in condition
falls
break in aseptic technique
patient refuses treatment
patient education Correct answer-influence patient behavior to: promote health, prevent illness,
restore health, facilitate coping
help patient and family develop self-care abilities: knowledge, skills, attitudes
learning domains Correct answer-cognitive, affective, psychomotor
factors affecting patient learning Correct answer-Age and developmental level
support resources
culture and language
literacy
teaching-learning process Correct answer-assess
identify learning needs (diagnose)
develop (planning)
implement teaching plan
evaluate learning
assess Correct answer-what learning needs does the patient have?
what is the patients learning readiness?
what is their motivation/health belief?
Develop (planning) Correct answer-contractual agreement
learning outcomes
teaching strategies
planning considerations
teaching strategies Correct answer--Role Modeling
-Lecture
-Discussion
-Panel Discussion
-Demonstration
-Role Playing
Correct Answers
Purpose of Records Correct answer-Communication
Nursing Documentation
Financial Billing
Auditing/Monitoring
Legal Documentations
Nursing Documentation Correct answer-observation: document assessment findings
intervention: what action was taken to abnormal assessment?
response: did patient improve?
Common Record-Keeping Forms Correct answer-admission forms
consents
advanced directives
flow sheets/graphic records
progress notes
nursing care plans
MAR
Confidentiality Correct answer-all patient information is confidential: written, computerized,
telephone, verbal, fax
protecting patient information: hard chart, computerized records, student clinical worksheets, phone
conversations
HIPAA Correct answer-Health Insurance Portability and Accountability Act
patients have the right to see and copy record, have the right to request restrictions
health information can only be released for: treatment, payment, routine health care operations
violation: $250,000 fine and 10 years in prison
Guidelines for quality documentation Correct answer-Factual
Accurate
Complete
Current
Organized
Documenting Guidelines Correct answer-pen
date and time
no mistakes in entry: no whiteout, scribbling
Initials and error
no blank lines
signature with credentials
initial nursing assessment Correct answer-thorough and complete
provides baseline
, Common methods of recording Correct answer-narrative documentation (most common)
PIE: problem, intervention, evaluation
DAR: data, action, response
SOAP: subjective, objective, assessment, plan
SOAPIE: subjective, objective, assessment, plan, Intervention, evaluation
Charting by exception (flow sheets)
Reporting Correct answer-ISBARR: situation, background, assessment, recommendation- gather all
data before calling physician
Verbal orders: read back verified
Incident report situations Correct answer-medication errors
complications from treatment/procedure
failure to report change in condition
falls
break in aseptic technique
patient refuses treatment
patient education Correct answer-influence patient behavior to: promote health, prevent illness,
restore health, facilitate coping
help patient and family develop self-care abilities: knowledge, skills, attitudes
learning domains Correct answer-cognitive, affective, psychomotor
factors affecting patient learning Correct answer-Age and developmental level
support resources
culture and language
literacy
teaching-learning process Correct answer-assess
identify learning needs (diagnose)
develop (planning)
implement teaching plan
evaluate learning
assess Correct answer-what learning needs does the patient have?
what is the patients learning readiness?
what is their motivation/health belief?
Develop (planning) Correct answer-contractual agreement
learning outcomes
teaching strategies
planning considerations
teaching strategies Correct answer--Role Modeling
-Lecture
-Discussion
-Panel Discussion
-Demonstration
-Role Playing
