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NRS-2024 FUNDAMENTAL Exam 1 Review Questions and Answers Fully Solved
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NRS-2024 FUNDAMENTAL Exam 1 Review
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NRS-2024 FUNDAMENTAL Exam 1Review
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's
following statements would appear at the beginning of a charting entry? - answerClient
complaining of abdominal pain rated at 8/10.
A nurse organizes client data using the SOAP format. Which of the following would be
recorded under "S" of this acronym? - answerClient complaints of pain
Which note includes all elements of a SOAP note? - answerClient reports nausea,
including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are
moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min.
Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1
hour for effectiveness.
The charge nurse is reviewing SOAP format documentation with a newly hired nurse.
What information should the charge nurse discuss? - answerSubjective data should be
included when documenting.
What is the nurse's best defense if a patient alleges nursing negligence? -
answerpatients record
A student has reviewed a client's chart before beginning assigned care. Which of the
following actions violates client confidentiality? - answerWriting the client's name on the
student care plan
What is confidential information? - answerAll information about patients is considered
private or confidential, whether written on paper, saved on a computer, or spoken aloud.
This includes patient names and all identifiers such as address, telephone and fax
number, Social Security number, and any other personal information. It also includes
the reason the patient is sick or in the hospital, office, or clinic, the assessments and
treatments the patient receives, and information about past health conditions
T/F. A nurse who fails to log off a computer after documenting patient care has
breached patient confidentiality - answerTrue
What is the primary purpose of the client record? - answerCommunication
What are other purposes of client record? - answerDiagnostic and therapeutic orders,
Care planning, Quality process and performance improvement, Research, decision
analysis, Education, Credentialing, regulation, and legislation; Reimbursement [used to
, demonstrate to payers (e.g., insurance companies) that patients received the intensity
and quality of care for which reimbursement is being sought], and Legal and historical
documentation (for court hearing)
What is the purpose of progress notes? - answerThe purpose of progress notes is to
inform caregivers of the progress a patient is making toward achieving expected
outcomes.
The method used to record the patient's progress depends on what? - answerThe
method used to record the patient's progress depends on the documentation system
being used. Common examples include narrative nursing notes, SOAP notes, PIE
notes, focus charting, CBE, and the case management model
What is a critical pathway & where is used? - answerCollaborative pathways—also
called critical pathways or care maps—are used in the case management model. The
collaborative pathway specifies the care plan linked to expected outcomes along a
timeline. It is a standardized care plan that is developed for a patient population with a
designated diagnosis or procedure. It includes expected outcomes, a list of
interventions to be performed, and the sequence and timing of those interventions.
T/F. CBE is frequently used with collaborative pathway documentation systems. -
answerTrue
T/F. In some documentation systems, the collaborative pathway is part of a
computerized documentation system that integrates the collaborative pathway and
documentation flow sheets designed to match each day's expected outcomes. -
answerTrue
What part of the client's record is commonly used to document specific client variables,
such as vital signs? - answerGraphic record/flow sheet
What is a flow sheet? - answerFlow sheets are documentation tools used to efficiently
record routine aspects of nursing care. Well-designed flow sheets enable nurses to
quickly document the routine aspects of care that promote patient goal achievement,
safety, and well-being.
What is a graphic record? - answerThe graphic record is a form used to record specific
patient variables such as pulse, respiratory rate, blood pressure readings, body
temperature, weight, fluid intake and output, bowel movements, and other patient
characteristics.
What are the types of Flow Sheets? - answerTypes of Flow Sheets: Graphic record, 24-
hour fluid balance record, Medication administration record (MAR), 24-hour patient care
record, & Acuity records.
What is the primary purpose of an incident report - answerMeans of identifying risk
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