NUR 229 Final Exam Questions and
Correct Answers
What are the aspects of critical thinking we covered? ✅-A systematic way to form and
shape one's thinking, functioning purposefully and exactingly.
-Evidence-based descriptions of behaviors that demonstrate the knowledge,
characteristics, and skills that promote critical thinking in clinical practice.
What are the competencies in critical thinking? ✅-Interpretation
-Analysis
-Evaluation
-Interference
-Explanation
-Self-regulation
What is confidential? ✅-All information about patients written on paper, spoken aloud,
saved on computer
-Name, address, phone, fax, social security number
-Reason the person is sick
-Treatments patient receives
-Information about past health conditions
What are potential breaches in patient confidentiality? ✅-Displaying information on a
public screen
-Sending confidential e-mail messages via public networks
-Sharing printers among units with differing functions
-Discarding copies of patient information in trash cans
-Don't put too many identifiers. Use initials.
-Holding conversations that can be overheard
-Faxing confidential information to unauthorized persons
-Sending confidential messages overheard on pagers
Does a patient have the right to obtain, review, and revise the patient information in his
or her health record? ✅-No
-A patient has the right to obtain and review, but not revise the patient information in his
or her health record.
-The patient cannot revise a progress note.
-The patient can have nurses or medical records change information about their own
health information that is incorrect.
What are the patient rights? ✅-See and copy their health record
-Update their personal health information-Ex. "Surgery on foot in October".
-Get a list of disclosures
-Request a restriction on certain uses or disclosures
,-Choose how to receive health information
What are the guidelines for change of shift/hand-off reports? ✅-Basic identifying
information about each patient: name, room number, bed designation, diagnosis, and
attending and consulting physicians
-Current appraisal of each patient's health status
-Current orders (especially any newly changed orders)
-Abnormal occurrences during your shift
-Any unfilled orders that need to be continued onto the next shift
-Patient/family questions, concerns, needs
-Reports on transfers/discharges
What can a nurse do in an Electronic Health Record? ✅-Call up the admission
assessment tool on the computer screen and key in patient data.
-Develop the care plan using computerized care plans.
-Add to the patient database as new data are identified and modify the care plan
accordingly.
-Receive a work list showing the treatments, procedures, and medications necessary
for each patient throughout the shift.
-Document care immediately, using computer terminal at the patient's bedside.
What are the most common charting mistakes? ✅-Failing to record pertinent health or
drug info
-Failing to record nursing actions
-Failing to record that meds have been given
-Recoding on the wrong chart
-Failing to document a discontinued med
-Failing to record drug reactions or changes in pt condition
-Transcribing orders improperly or transcribing improper orders
-Writing illegible or incomplete records
What is narrative charting? ✅Means of recording patient data that enables doctors and
nurses to consult a pt status and plan future treatment quickly and effectively.
What does SOAP stand for? ✅Subjective, Objective, Assessment, and Planning
What does SOAPIE stand for? ✅Subjective, Objective, Assessment, Plan,
Implementation, and Evaluation
What does PIE stand for? ✅Problem-Intervention-Evaluation
What does DAR stand for? ✅-Data-Action-Response
What is important to remember to do when giving a telephone report? ✅1. Identify
yourself and the patient and state relationship to the patient.
, 2. Report concisely and accurately the change in the patient's condition that is of
concern and what has already been done in response to this condition.
3. Report the patient's current vital signs and clinical manifestations.
4. Have the patient's record at hand to make knowledgeable responses to any
physician's inquiries.
What is the format for giving a telephone/hand-off report? ✅-Introduction
-Situation
-Background
-Assessment
-Recommendation
-Read back orders
What is the policy for receiving verbal orders in an emergency? ✅-Record the orders in
patient's medical record.
-Read back the order to verify accuracy.
-Date and note the time orders were issued in emergency.
-Record verbal order and name of the physician issuing the order, followed by nurse's
name and initials.
When should there be an incident report? ✅Any time a patient makes a complaint, a
med error occurs, a medical device malfunctions, or anyone is injured or involved in a
situation with potential injury.
What is the nurses role in informed consent? ✅Obtaining and witnessing written
consent for healthcare treatment.
What is the policy for informed consent? ✅-Must be 18 to provide consent.
-Need to have informed and voluntary consent for admission for each specialized
diagnostic or treatment procedure, and for any experimental treatments or procedures.
-Must be written, designated for the procedure to be performed, and signed by the
patient or person legally responsible for them.
What is the different between subjective and objective data? ✅-Subjective: anything
that the patient states that can be perceived by only them.
-Objective: data that the nurse collects just by observing or measuring.
What are the different types of data collection methods/sources? ✅-Client
-Family and significant others
-Patient records
-Other health care professionals
-Nursing and other health care literature
How do you validate data? ✅-Recheck data via repeat assessment
-Clarify data with client by asking more questions
, -Verify data with another health care professional
-Compare objective findings with subjective findings to uncover discrepancies
How do you distinguish between normal and abnormal data/information? ✅-Look at
trends to see if it is out of the ordinary in their records for the patient.
-How does this patient's data compare with standards for someone in this age group,
culture, disease process and lifestyle?
-What medications may influence normal functions?
-How does the current data compare with any baseline data?
-Are these abnormal or normal findings (in general)?
What is data clustering? ✅-Deciding what clusters might say about general
functioning.
-Ex: Cues- chronic productive cough, wheezing, exercise intolerance, impaired
respiratory function
What is the difference between a medical diagnosis and a nursing diagnosis? ✅-A
nursing diagnosis deals with the human response to actual or potential health problems
and life processes.
-A medical diagnosis deals with the disease or medical condition.
What is the PES format? ✅-Problem
"related to"
-Etiology (suspected cause for problem)
"as evidence by"
-Signs and symptoms (cues identified in the assessment that substantiate the nursing
diagnosis)
What is the difference between an actual nursing diagnosis and a risk? ✅-Actual:
identifies a current health problem, such as inadequate airway clearance related to
(cause) as evidenced by the inability to maintain adequate oxygenation on room air.
-Risk: identifies when a patient could be at risk for additional health problems, such as
impaired skin integrity.
What are the high, intermediate, and low priorities in Maslow's hierarchy of needs? ✅1.
Psychologic needs (oxygen, food, water, sleep, warmth)
2. Security needs (safety, shelter, stability)
3. Love and belonging needs
4. Self-esteem needs (power, recognition, prestige)
5. Self actualization needs (development, creativity)
What is the difference between long term and short term goals? ✅-Long term require a
longer period to be achieved and may be used as discharge goals.
-Short term may be accomplished in a specific period of time.
