Documenting and Reporting- Foundations Questions with Complete Solutions
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Course
Nursing Reporting- Foundations
Institution
Nursing Reporting- Foundations
Documenting and Reporting-
Foundations Questions with Complete
Solutions
How should a nurse document a patient’s pain level?
Use a standardized pain scale, note the level of pain reported, any relevant descriptions, and
the effectiveness of interventions provided.
What is the purpose...
Documenting and Reporting-
Foundations Questions with Complete
Solutions
How should a nurse document a patient’s pain level?
✔✔ Use a standardized pain scale, note the level of pain reported, any relevant descriptions, and
the effectiveness of interventions provided.
What is the purpose of documenting nursing assessments?
✔✔ To record the patient’s physical and emotional status, track changes over time, and guide
ongoing care planning.
How should a nurse document unusual or adverse events?
✔✔ Clearly describe the event, including the time, place, individuals involved, and any
immediate actions taken, while avoiding speculation or blame.
What should be included in a discharge summary?
✔✔ Patient’s condition at discharge, instructions for follow-up care, medications prescribed, and
any specific recommendations or precautions.
1
,How can a nurse ensure confidentiality when documenting patient information?
✔✔ Use secure systems for electronic records, avoid leaving paper documents in accessible
areas, and follow policies for handling sensitive information.
What is the importance of documenting a patient’s response to treatment?
✔✔ To evaluate the effectiveness of the treatment, guide future care decisions, and provide a
record for continuity of care.
How should a nurse document communication with a patient’s family?
✔✔ Record the details of the conversation, including the date, time, the topics discussed, and the
family’s questions or concerns.
What information should be included in an incident report?
✔✔ The nature of the incident, involved individuals, any immediate actions taken, and the
impact on patient care or safety.
How should a nurse document a patient’s refusal to participate in a recommended procedure?
✔✔ Note the patient’s refusal, the rationale provided, any potential consequences discussed, and
any alternative plans made.
2
, What should be included in documentation of a patient’s nutritional intake?
✔✔ Record the types and amounts of food and fluids consumed, any dietary restrictions, and
observations related to the patient’s nutritional status.
How should a nurse document the outcome of a patient’s diagnostic test?
✔✔ Include the test results, the date and time of the test, and any follow-up actions or
interpretations related to the results.
What is the primary goal of nursing documentation?
✔✔ To provide an accurate and comprehensive record of patient care and treatment.
How should a nurse document a patient’s refusal of medication?
✔✔ Note the patient’s refusal, the reason given, and any actions taken to address or educate the
patient.
What should be included in a nursing progress note?
✔✔ The patient’s current condition, any changes in status, interventions performed, and the
outcomes of those interventions.
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