Nursing 1201 Final Exam 2 Questions
and All Correct Answers 2025-2026
Updated.
Occurrence Reporting (incident report) - Answer - a formal record of an unusual occurrence or
accident.
- it is an organizational report; NOT PART OF THE PATIENTS MEDICAL RECORD.
- Hep track problems/identify areas of quality improvement and create safer processes and
procedures for clients and staff.
SBAR - Answer situation, background, assessment, recommendation
PACE - Answer patient/problem, assessment/actions, continuing/changes, evaluation
Purpose of reporting client data. - Answer 1. maintain continuity of care.
2. provides professional communication
3. assists in organizing your work
4. builds team relationships
5. collaborative to improve patient care
Various methods of documentation - Answer 1. source oriented record system
2. problem oriented record system
3. charting by exception
4. electronic health record (EHR) system
Disadvantages to nursing informatics. - Answer 1. expensive
2. downtime
3. difficulties associated with change
4. lack of intigrations
Advantages of nursing informatics. - Answer 1. enhanced communication and collaboration
, How to fix a charting error. - Answer - draw a line through the incorrect charting and initial it.
- never use correction fluid
- never scribble over or cover charting otherwise in written notes
Purposes of documentation - Answer 1. communication
2. legal record
3. continuity of care
4. quality improvement
5. reimbursement
What is documentation? - Answer - the act of recording patient status and care in written or
electronic form, or a combination of 2 forms.
- the act of making written record
How do you evaluate client progress? - Answer 1. review outcomes
2. collect reassessment data
3. judge goal achievement
4. record and evaluate statement
5. evaluate collaborative problems
Common errors of evaluation - Answer - failing to evaluate systematically
- failing to record results
- failing to use reassessment data to re-examine and modify care plan
Nursing intervention - Answer Actions based on clinical judgement and nursing knowledge,
that nurses perform to achieve client outcomes. AKA: nursing actions, measures, strategies, or
activities.
What is implementation? - Answer Performing or delegation of planned interventions. (ends
when you document the nursing action and evaluation begins)
and All Correct Answers 2025-2026
Updated.
Occurrence Reporting (incident report) - Answer - a formal record of an unusual occurrence or
accident.
- it is an organizational report; NOT PART OF THE PATIENTS MEDICAL RECORD.
- Hep track problems/identify areas of quality improvement and create safer processes and
procedures for clients and staff.
SBAR - Answer situation, background, assessment, recommendation
PACE - Answer patient/problem, assessment/actions, continuing/changes, evaluation
Purpose of reporting client data. - Answer 1. maintain continuity of care.
2. provides professional communication
3. assists in organizing your work
4. builds team relationships
5. collaborative to improve patient care
Various methods of documentation - Answer 1. source oriented record system
2. problem oriented record system
3. charting by exception
4. electronic health record (EHR) system
Disadvantages to nursing informatics. - Answer 1. expensive
2. downtime
3. difficulties associated with change
4. lack of intigrations
Advantages of nursing informatics. - Answer 1. enhanced communication and collaboration
, How to fix a charting error. - Answer - draw a line through the incorrect charting and initial it.
- never use correction fluid
- never scribble over or cover charting otherwise in written notes
Purposes of documentation - Answer 1. communication
2. legal record
3. continuity of care
4. quality improvement
5. reimbursement
What is documentation? - Answer - the act of recording patient status and care in written or
electronic form, or a combination of 2 forms.
- the act of making written record
How do you evaluate client progress? - Answer 1. review outcomes
2. collect reassessment data
3. judge goal achievement
4. record and evaluate statement
5. evaluate collaborative problems
Common errors of evaluation - Answer - failing to evaluate systematically
- failing to record results
- failing to use reassessment data to re-examine and modify care plan
Nursing intervention - Answer Actions based on clinical judgement and nursing knowledge,
that nurses perform to achieve client outcomes. AKA: nursing actions, measures, strategies, or
activities.
What is implementation? - Answer Performing or delegation of planned interventions. (ends
when you document the nursing action and evaluation begins)
