NCLEX practice questions documentation
(Latest Update ) Questions &
Verified Answers 100% Correct [Grade A]-
Chamberlain
Documentation is:
A) Anything written or printed that you rely on as record or proof for authorized
persons.
B) Lab results for a patient you are taking care of.
C) Admission paperwork for billing purposes.
D) Instructions from the attending doctor. - correct answer A
A nurse preceptor is working with a student nurse. Which behavior by the student
nurse will
require the nurse preceptor to intervene?
a. The student nurse reviews the patient's medical record.
b. The student nurse reads the patient's plan of care.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient - correct
answer ANS: C
When you are a student in a clinical setting, confidentiality and compliance with the
Health Insurance Portability and Accountability Act (HIPAA) are part of professional
practice. When a student nurse shares patient information with a friend, confidentiality
and HIPAA standards
have been violated. You can review your patients' medical records only to seek
information needed to provide safe and effective patient care. For example, when you
are assigned to care for a patient, you need to review the patient's medical record and
plan of care. You do not
share this information with classmates and you do not access the medical records of
other patients on the unit
Accreditation is:
A) Certification by the ANA.
B) Medicare approval.
C) Joint Commission specifies guidelines for documentation.
D) Passing the NCLEX. - correct answer C
A nurse prepared an audiotaped exchange with another nurse of information about a
patient.
,NCLEX practice questions documentation
(Latest Update ) Questions &
Verified Answers 100% Correct [Grade A]-
Chamberlain
Which action did the nurse complete? The nurse completed a
a. Report.
b. Record.
c. Consultation.
d. Referral - correct answer ANS: A
Reports are oral, written, or audiotaped exchanges of information among caregivers. A
patient's record or chart is a confidential, permanent legal document consisting of
information relevant to his or her health care. Consultations are another form of
discussion in which one
professional caregiver gives formal advice about the care of a patient to another
caregiver. Nurses document referrals (arrangements for the services of another care
provider).
Which of the following is correctly charted according to the six guidelines for quality
recording?
A: "Was depressed today"
B:"respirations rapid; lung sounds clear"
C:"Had a good day. Up and about in room."
D:"Crying. States she does not want visitors to see her like this" - correct answer D:
reason you need to document pt. exact words in quotations when recording subjective
data.
Explain the new rights for clients related to HIPPA.
A) Patient right to leave healthcare facility.
B) Patient education on privacy protections
C) Patient's right to access their medical records.
D) Provider must receive consent from patient before releasing information.
E) Recourse options if privacy protections are violated. - correct answer B, C, D, E
Which situation best indicates that the nurse has a good understanding regarding
auditing and monitoring of patients' health records?
a. The nurse determines the degree to which standards of care are met by reviewing
patients' health records.
,NCLEX practice questions documentation
(Latest Update ) Questions &
Verified Answers 100% Correct [Grade A]-
Chamberlain
b. The nurse realizes that care not documented in patients' health records still
qualifies as care provided.
c. The nurse knows that reimbursement is based on the diagnosis-related groups
documented in patients' records.
d. The nurse compares data in patients' records to determine whether a new treatment
had better outcomes than the standard treatment. - correct answer ANS: A
The patient record is a valuable source of data for all members of the health care
team. Its purposes include communication, legal documentation, financial billing,
education, research, and auditing/monitoring. The auditing/monitoring purpose
involves nurses auditing records throughout the year to determine the degree to which
standards of care are met and to identify areas needing improvement and staff
development. The legal documentation purpose involves the concept that even though
nursing care may have been excellent, in a court of law, "care not documented is care
not provided." The financial billing or reimbursement purpose involves diagnosis-
related groups (DRGs) as the basis for establishing reimbursement for patient care.
For research purposes, the researcher compares the patient's recorded findings to
determine whether the new method was more effective than the standard protocol.
Analysis of data from research contributes to evidence-based nursing practice and
quality health care
The standards of documentation by the Joint Commission require:
A) Narrative on how patient was cared for.
B) Patient's vital signs every 4 hours.
C) A resolution date for all planned outcomes.
D) Documentation within the context of the nursing process, as well as evidence of
client and family teaching and discharge planning. - correct answer D
After providing care, a nurse charts in the patient's record. Which entry should the
nurse
document?
a. Appears restless when sitting in the chair
b. Drank adequate amounts of water
c. Apparently is asleep with eyes closed
d. Skin pale and cool - correct answer ANS: D
, NCLEX practice questions documentation
(Latest Update ) Questions &
Verified Answers 100% Correct [Grade A]-
Chamberlain
A factual record contains descriptive, objective information about what a nurse sees,
hears, feels, and smells. An objective description is the result of direct observation and
measurement. For example, "B/P 80/50, patient diaphoretic, heart rate 102 and
regular." Avoid vague terms such as appears, seems, or apparently because these
words suggest that you are stating an opinion, do not accurately communicate facts,
and do not inform another caregiver of details regarding behaviors exhibited by the
patient. Use of exact measurements establishes accuracy. For example, a description
such as "Intake, 360 mL of water" is more accurate than "Patient drank an adequate
amount of fluid."
If an error is made while recording, the nurse should:
A: erase it or scratch it out
B: leave a blank space in the note.
C: Draw a single line through the error and initial it
D: obtain a new nurse's note and rewrite the entries - correct answer C
A nurse has provided care to a patient. Which entry should the nurse document in the
patient's
record?
a. "Patient seems to be in pain and states, 'I feel uncomfortable.'"
b. Status unchanged, doing well
c. Left abdominal incision 1 inch in length without redness, drainage, or edema
d. Patient is hard to care for and refuses all treatments and medications. Family
present - correct answer ANS: C
Use of exact measurements establishes accuracy. Charting that an abdominal wound
is "5 cm in length without redness, drainage, or edema" is more descriptive than "large
wound healing well." Include objective data to support subjective data, so your charting
is as descriptive as possible. Avoid using generalized, empty phrases such as "status
unchanged" or "had a good day." It is essential to avoid the use of unnecessary words
and irrelevant details or personal opinions. "Patient is hard to care for" is a personal
opinion and should be avoided. It is also a
critical comment that can be used as evidence for nonprofessional behavior or poor
quality of care. Just chart, "Refuses all treatments and medications."
(Latest Update ) Questions &
Verified Answers 100% Correct [Grade A]-
Chamberlain
Documentation is:
A) Anything written or printed that you rely on as record or proof for authorized
persons.
B) Lab results for a patient you are taking care of.
C) Admission paperwork for billing purposes.
D) Instructions from the attending doctor. - correct answer A
A nurse preceptor is working with a student nurse. Which behavior by the student
nurse will
require the nurse preceptor to intervene?
a. The student nurse reviews the patient's medical record.
b. The student nurse reads the patient's plan of care.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient - correct
answer ANS: C
When you are a student in a clinical setting, confidentiality and compliance with the
Health Insurance Portability and Accountability Act (HIPAA) are part of professional
practice. When a student nurse shares patient information with a friend, confidentiality
and HIPAA standards
have been violated. You can review your patients' medical records only to seek
information needed to provide safe and effective patient care. For example, when you
are assigned to care for a patient, you need to review the patient's medical record and
plan of care. You do not
share this information with classmates and you do not access the medical records of
other patients on the unit
Accreditation is:
A) Certification by the ANA.
B) Medicare approval.
C) Joint Commission specifies guidelines for documentation.
D) Passing the NCLEX. - correct answer C
A nurse prepared an audiotaped exchange with another nurse of information about a
patient.
,NCLEX practice questions documentation
(Latest Update ) Questions &
Verified Answers 100% Correct [Grade A]-
Chamberlain
Which action did the nurse complete? The nurse completed a
a. Report.
b. Record.
c. Consultation.
d. Referral - correct answer ANS: A
Reports are oral, written, or audiotaped exchanges of information among caregivers. A
patient's record or chart is a confidential, permanent legal document consisting of
information relevant to his or her health care. Consultations are another form of
discussion in which one
professional caregiver gives formal advice about the care of a patient to another
caregiver. Nurses document referrals (arrangements for the services of another care
provider).
Which of the following is correctly charted according to the six guidelines for quality
recording?
A: "Was depressed today"
B:"respirations rapid; lung sounds clear"
C:"Had a good day. Up and about in room."
D:"Crying. States she does not want visitors to see her like this" - correct answer D:
reason you need to document pt. exact words in quotations when recording subjective
data.
Explain the new rights for clients related to HIPPA.
A) Patient right to leave healthcare facility.
B) Patient education on privacy protections
C) Patient's right to access their medical records.
D) Provider must receive consent from patient before releasing information.
E) Recourse options if privacy protections are violated. - correct answer B, C, D, E
Which situation best indicates that the nurse has a good understanding regarding
auditing and monitoring of patients' health records?
a. The nurse determines the degree to which standards of care are met by reviewing
patients' health records.
,NCLEX practice questions documentation
(Latest Update ) Questions &
Verified Answers 100% Correct [Grade A]-
Chamberlain
b. The nurse realizes that care not documented in patients' health records still
qualifies as care provided.
c. The nurse knows that reimbursement is based on the diagnosis-related groups
documented in patients' records.
d. The nurse compares data in patients' records to determine whether a new treatment
had better outcomes than the standard treatment. - correct answer ANS: A
The patient record is a valuable source of data for all members of the health care
team. Its purposes include communication, legal documentation, financial billing,
education, research, and auditing/monitoring. The auditing/monitoring purpose
involves nurses auditing records throughout the year to determine the degree to which
standards of care are met and to identify areas needing improvement and staff
development. The legal documentation purpose involves the concept that even though
nursing care may have been excellent, in a court of law, "care not documented is care
not provided." The financial billing or reimbursement purpose involves diagnosis-
related groups (DRGs) as the basis for establishing reimbursement for patient care.
For research purposes, the researcher compares the patient's recorded findings to
determine whether the new method was more effective than the standard protocol.
Analysis of data from research contributes to evidence-based nursing practice and
quality health care
The standards of documentation by the Joint Commission require:
A) Narrative on how patient was cared for.
B) Patient's vital signs every 4 hours.
C) A resolution date for all planned outcomes.
D) Documentation within the context of the nursing process, as well as evidence of
client and family teaching and discharge planning. - correct answer D
After providing care, a nurse charts in the patient's record. Which entry should the
nurse
document?
a. Appears restless when sitting in the chair
b. Drank adequate amounts of water
c. Apparently is asleep with eyes closed
d. Skin pale and cool - correct answer ANS: D
, NCLEX practice questions documentation
(Latest Update ) Questions &
Verified Answers 100% Correct [Grade A]-
Chamberlain
A factual record contains descriptive, objective information about what a nurse sees,
hears, feels, and smells. An objective description is the result of direct observation and
measurement. For example, "B/P 80/50, patient diaphoretic, heart rate 102 and
regular." Avoid vague terms such as appears, seems, or apparently because these
words suggest that you are stating an opinion, do not accurately communicate facts,
and do not inform another caregiver of details regarding behaviors exhibited by the
patient. Use of exact measurements establishes accuracy. For example, a description
such as "Intake, 360 mL of water" is more accurate than "Patient drank an adequate
amount of fluid."
If an error is made while recording, the nurse should:
A: erase it or scratch it out
B: leave a blank space in the note.
C: Draw a single line through the error and initial it
D: obtain a new nurse's note and rewrite the entries - correct answer C
A nurse has provided care to a patient. Which entry should the nurse document in the
patient's
record?
a. "Patient seems to be in pain and states, 'I feel uncomfortable.'"
b. Status unchanged, doing well
c. Left abdominal incision 1 inch in length without redness, drainage, or edema
d. Patient is hard to care for and refuses all treatments and medications. Family
present - correct answer ANS: C
Use of exact measurements establishes accuracy. Charting that an abdominal wound
is "5 cm in length without redness, drainage, or edema" is more descriptive than "large
wound healing well." Include objective data to support subjective data, so your charting
is as descriptive as possible. Avoid using generalized, empty phrases such as "status
unchanged" or "had a good day." It is essential to avoid the use of unnecessary words
and irrelevant details or personal opinions. "Patient is hard to care for" is a personal
opinion and should be avoided. It is also a
critical comment that can be used as evidence for nonprofessional behavior or poor
quality of care. Just chart, "Refuses all treatments and medications."
