Fundamentals Midterm review: Nursing process and documentation

What is the nursing process?

• framework within which nurses provide care in an organized and effective manner

• a series of steps to diagnose and treat physical health problems

• A framework used to assess the financial needs of patients

• A strict protocol nurses must follow for every patient without changes

What are the correct steps of the nursing process?

• Planning, diagnosis, assessment, implementation, and evaluation

• Assessment, Nursing diagnosis, planning, implementation, and evaluation

• Assessment, diagnosis, planning, evaluation, and implementation

• Planning, assessment, diagnosis, implementation, and evaluation

What is confidentiality?

• Sharing patient information with anyone involved in their care, including family and friends

• Posting patient updates on social media for transparency

• Allowing healthcare providers to discuss a patient’s condition with other patients for educational purposes

• Nurses have a professional and legal obligation to protect patient information and only share with the care team and approved personel

What type of nursing documentation is used during a bedside handoff report?

• SOAP notes

• PIE notes

• APIE notes

• DAR notes

What does PIE notes stand for?

• Patient Information Evaluation

• Problem, Intervention, Evaluation

• Plan, Implement, Examine

• Procedure, Inspection, Execution

What does HIPAA stand for?

• Health Information Privacy and Accountability Act

• Health Insurance Privacy and Accountability Act

• Health Information Portability and Accountability Act

• Health Insurance Portability and Accountability Act

During which step of the nursing process would the nurse identify possible health problems based on assessment data?

• Planning

• Implementation

• Diagnosis

• Evaluation

For the planning phase of the nursing process, which of the following must be done in order to set realistic patient goals?

• Conducting a comprehensive assessment

• Collaborating with the healthcare team

• Understanding the patient’s preferences/values

• all of the above

During the evaluation phase, the nurse finds that the patient’s condition has not improved as expected. Which is the best response to this scenario?

• Ignore these findings

• Change the diagnosis

• Implement the same plan more vigorously

• Reassess the patient and modify the care plan

A telephone order, when absolutely necessary, must be taken by an RN who what?

• Places the order immediately.

• Repeats the order back to the physician verbatim.

• Documents the order at a later time.

• Doesn’t worry about documentation because it is an emergency.