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CSN Nursing 101 Exam 4 Questions with Latest Update
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CSN Nursing 101 Exam 4 Questions with Latest Update
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CSN Nursing 101 Exam 4 Questions withLatest Update
Purpose of Records - Answer-Communication
Nursing Documentation
Financial Billing
Auditing/Monitoring
Legal Documentations
Nursing Documentation - Answer-observation: document assessment findings
intervention: what action was taken to abnormal assessment?
response: did patient improve?
Common Record-Keeping Forms - Answer-admission forms
consents
advanced directives
flow sheets/graphic records
progress notes
nursing care plans
MAR
Confidentiality - Answer-all patient information is confidential: written, computerized,
telephone, verbal, fax
protecting patient information: hard chart, computerized records, student clinical
worksheets, phone conversations
HIPAA - Answer-Health Insurance Portability and Accountability Act
patients have the right to see and copy record, have the right to request restrictions
health information can only be released for: treatment, payment, routine health care
operations
violation: $250,000 fine and 10 years in prison
Guidelines for quality documentation - Answer-Factual
Accurate
Complete
Current
Organized
Documenting Guidelines - Answer-pen
date and time
no mistakes in entry: no whiteout, scribbling
, Initials and error
no blank lines
signature with credentials
initial nursing assessment - Answer-thorough and complete
provides baseline
Common methods of recording - Answer-narrative documentation (most common)
PIE: problem, intervention, evaluation
DAR: data, action, response
SOAP: subjective, objective, assessment, plan
SOAPIE: subjective, objective, assessment, plan, Intervention, evaluation
Charting by exception (flow sheets)
Reporting - Answer-ISBARR: situation, background, assessment, recommendation-
gather all data before calling physician
Verbal orders: read back verified
Incident report situations - Answer-medication errors
complications from treatment/procedure
failure to report change in condition
falls
break in aseptic technique
patient refuses treatment
patient education - Answer-influence patient behavior to: promote health, prevent
illness, restore health, facilitate coping
help patient and family develop self-care abilities: knowledge, skills, attitudes
learning domains - Answer-cognitive, affective, psychomotor
factors affecting patient learning - Answer-Age and developmental level
support resources
culture and language
literacy
teaching-learning process - Answer-assess
identify learning needs (diagnose)
develop (planning)
implement teaching plan
evaluate learning
assess - Answer-what learning needs does the patient have?
what is the patients learning readiness?
what is their motivation/health belief?
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