1|Page
ADULT NURSING 1 EXAM 1 STUDY GUIDE /
COMPREHENSIVE KEY QUESTIONS WITH
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
,2|Page
-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)
, 3|Page
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
ADULT NURSING 1 EXAM 1 STUDY GUIDE /
COMPREHENSIVE KEY QUESTIONS WITH
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
,2|Page
-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)
, 3|Page
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
