Nursing Documentation Questions and Answers with Verified Solutions
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Module
Nursing
Institution
Nursing
Nursing Documentation Questions and
Answers with Verified Solutions
1. What is the primary purpose of nursing documentation?
A) To fulfill legal requirements
B) To communicate with other healthcare providers
C) To keep records of patient billing
D) To complete administrative tasks
B) ...
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Nursing Documentation Questions and
Answers with Verified Solutions
1. What is the primary purpose of nursing documentation?
A) To fulfill legal requirements
B) To communicate with other healthcare providers
C) To keep records of patient billing
D) To complete administrative tasks
✔✔ B) To communicate with other healthcare providers
Rationale: The primary purpose of nursing documentation is to communicate patient
information, care provided, and any changes in the patient's condition among healthcare
providers to ensure continuity of care.
2. When documenting a patient's refusal of medication, what is the most important detail to
include?
A) The name of the medication
B) The reason for refusal
1
,C) The time of refusal
D) The medication's side effects
✔✔ B) The reason for refusal
Rationale: The reason for refusal is crucial as it helps in understanding the patient’s perspective
and in making necessary adjustments to the treatment plan.
3. How should a nurse document a patient’s response to a new treatment plan?
A) Only note positive responses
B) Record all observed responses, both positive and negative
C) Document the treatment plan without noting responses
D) Only document if the response is severe
✔✔ B) Record all observed responses, both positive and negative
Rationale: Documenting all responses, both positive and negative, provides a comprehensive
view of the treatment’s effectiveness and any adverse effects, which is essential for ongoing
patient care.
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, 4. What is a key component of effective documentation in electronic health records (EHR)?
A) Using medical jargon to be precise
B) Including patient opinions in detail
C) Ensuring all entries are accurate and timely
D) Documenting only significant changes
✔✔ C) Ensuring all entries are accurate and timely
Rationale: Accuracy and timeliness are critical in EHR documentation to ensure that patient
records reflect the current state of health and care provided, facilitating effective communication
and decision-making.
5. What should be documented if a patient demonstrates non-compliance with a care plan?
A) The patient’s overall health status
B) The specific non-compliance issues and patient’s reasons
C) The names of all involved healthcare providers
D) The patient’s medical history
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