Nursing Documenting and Reporting
Questions and Answers Already Passed
What key elements should be included when documenting a patient’s wound care?
✔✔ The size, location, and appearance of the wound, the type of dressing applied, and the
patient’s response to the treatment.
How should a nurse document a patient’s response to physical therapy?
✔✔ Note the exercises performed, the patient’s level of comfort or discomfort, progress made,
and any modifications to the therapy.
What should be recorded when a patient expresses concerns about their treatment plan?
✔✔ Document the specific concerns raised, the patient’s rationale, any discussions held, and the
resolutions or adjustments made.
When documenting a patient’s vital signs, what additional information might be relevant?
✔✔ Include any patient activities prior to measurement, any symptoms experienced at the time,
and how the vital signs compare to previous measurements.
1
, How should a nurse document a patient’s ability to perform activities of daily living (ADLs)?
✔✔ Record the specific ADLs assessed, the level of assistance required, and any changes in the
patient’s ability to perform these tasks independently.
What should a nurse include in documentation following a patient’s discharge from the hospital?
✔✔ The patient’s condition at discharge, any follow-up appointments or instructions given, and
the condition of the home environment if relevant.
How should changes in a patient’s mental status be documented?
✔✔ Describe any observed changes in cognition, mood, or behavior, including the time of
occurrence and any factors that may have contributed to the changes.
What information should be documented when a patient receives a new prescription?
✔✔ Document the medication name, dosage, administration route, any instructions given to the
patient, and the patient’s understanding of the new medication.
How should a nurse document a patient’s response to a dietary change?
✔✔ Record the type of dietary change, the patient’s adherence to the new diet, any symptoms or
reactions experienced, and any observed improvements or issues.
2
Questions and Answers Already Passed
What key elements should be included when documenting a patient’s wound care?
✔✔ The size, location, and appearance of the wound, the type of dressing applied, and the
patient’s response to the treatment.
How should a nurse document a patient’s response to physical therapy?
✔✔ Note the exercises performed, the patient’s level of comfort or discomfort, progress made,
and any modifications to the therapy.
What should be recorded when a patient expresses concerns about their treatment plan?
✔✔ Document the specific concerns raised, the patient’s rationale, any discussions held, and the
resolutions or adjustments made.
When documenting a patient’s vital signs, what additional information might be relevant?
✔✔ Include any patient activities prior to measurement, any symptoms experienced at the time,
and how the vital signs compare to previous measurements.
1
, How should a nurse document a patient’s ability to perform activities of daily living (ADLs)?
✔✔ Record the specific ADLs assessed, the level of assistance required, and any changes in the
patient’s ability to perform these tasks independently.
What should a nurse include in documentation following a patient’s discharge from the hospital?
✔✔ The patient’s condition at discharge, any follow-up appointments or instructions given, and
the condition of the home environment if relevant.
How should changes in a patient’s mental status be documented?
✔✔ Describe any observed changes in cognition, mood, or behavior, including the time of
occurrence and any factors that may have contributed to the changes.
What information should be documented when a patient receives a new prescription?
✔✔ Document the medication name, dosage, administration route, any instructions given to the
patient, and the patient’s understanding of the new medication.
How should a nurse document a patient’s response to a dietary change?
✔✔ Record the type of dietary change, the patient’s adherence to the new diet, any symptoms or
reactions experienced, and any observed improvements or issues.
2
