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WorksheetsFundamentals Midterm review: Nursing process and documentation
Total questions: 18
Worksheet time: 10mins
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.
When assessing speech in a general survey, which of the answers below is not included?
Articulation
Fluency
Word choice
Slang words
Which of the following is not included in the overall impression of the patient?
Begins at first contact.
Continues throughout the assessment.
Subjective data
Objective data
Creating a nursing solution to treat the patient's plaque psoriasis would be including in which part of the nursing process?
Implementation
Assesment
Planning
Evaluation
Which type of nursing diagnosis is this? "Acute pain related to right lower quadrant of abdomen as evidenced by surgical incision and patient rating their pain a 10/10"
Actual nursing diagnosis
Risk nursing diagnosis
health promotion diagnosis
I thought diagnosing was the doctor's job?
What is true of documentation?
It must be accurate and concise
It can be used as a legal document in a court of law
It is appropriate to back-chart if you get busy and can't write it down right now
It must be done at the time of care
What must be done/included by the RN taking a telephone order?
Repeating the order verbatim
Document the order as an electronic order
Can be taken by a UAP
Include the date, time, physician's name, and RN signature
When giving an SBAR report, you update, the doctor with the patient's most recent vitals and their pain level. Which category of SBAR would that fall under?
Situation
background
assessment
recommendation
Go ______
Bearcats!
Bengals! Who Dey?
FC Cincy!
Prof Beecher!
