Test Bank for Fundamentals of Nursing 3rd Edition by Yoost All Chapters

Test Bank for Fundamentals of Nursing 3rd Edition by Yoost All Chapters

 

 

 

 

 

 

 

 

 

 

Independent nursing interventions are tasks within the nursing scope of practice that the nurse

may undertake without a physician or PCP order. Repositioning a patient in bed, performing

oral hygiene, and providing emotional support through active listening are examples of

independent nursing interventions. Dependent nursing interventions are tasks the nurse

undertakes that are within the nursing scope of practice but require the order of a primary care

provider to be implemented. Administering patient medications or administering oxygen to a

patient are examples of common dependent nursing interventions that require clinical

judgment before implementation. These interventions are based on a collaborative effort of

the nurse and the physician to provide care to patients. 

DIF:   Evaluating      OBJ:   9.4                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination 

9.   The nurse recognizes which topic is appropriate teaching content for the patient who is

returning from surgery? 

a.  

Signs and symptoms of infection 

b.  

Use of patient-controlled analgesia 

c.  

Activity limitations upon discharge 

d.  

Physical therapy 

ANS:  B 

Readiness to learn is an important consideration. For example, when a patient returns from

surgery, it is essential that some information be reviewed (e.g., how to use the

patient-controlled analgesia pump and incentive spirometer) but completing all discharge

teaching at this time would not be effective. At other times, teaching is more formalized, such

as discharge teaching, signs o

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al therapy.

 

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DIF:   Analyzing       OBJ:   9.2                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity: Health Promotion and Maintenance

NOT:  Concepts: Care Coordination 

10.   The nurse is learning to identify readiness to learn in patients. Which patient would the nurse

identify correctly as ready to learn? 

a.  

The patient requesting pain medication for treatment of severe discomfort 

b.  

The patient reporting nausea and vomiting 

c.  

The patient who was just told the diagnosis of cancer of the pancreas 

d.  

The patient who was recently diagnosed with diabetes mellitus and is scheduled to

be discharged in 2 days 

ANS:  D 

Choosing opportunities when the patient’s condition and environment are most conducive to

learning is recommended when attempting to teach patients. Patients who are in pain, are

nauseated, or who have been given recent traumatic diagnoses are not psychologically able to

retain information. 

DIF:   Evaluating      OBJ:   9.4                   TOP:  Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Health Promotion and Maintenance

NOT:  Concepts: Care Coordination

 

 

 

 

 

 

 

 

 

 

 

11.   The nurse asks the patient for permission to involve the patient’s family members in the

teaching plan for the patient. Which response is the best rationale to support this involvement? 

a.

Involving the family empowers the patients and their support system. 

b.  

Teaching family members decreases the number of questions they may ask. 

c.  

Educated family members ensure the patient will comply with the treatment plan. 

d.  

The family members may be interested in the information. 

ANS:  A 

With the patient’s permission, the nurse should share instructions with the people who may

assist with care. Nurses empower patients and their support systems through effective

teaching. When nurses provide patients and their families with opportunities to ask questions

and comprehend health care information, they become an integral part of the health care

process. The family members may ask fewer questions but that is not a reason to involve

them. Nothing will ensure patient compliance other that the patient deciding to do so. Family

members may be interested in the information, but that is not the main reason to include them. 

DIF:   Analyzing       OBJ:   9.2                   TOP:  Planning

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 

NOT:  Concepts: Care Coordination 

12.   The nurse identifies change-of-shift report, collaboration with other health care members, and

ensuring availability of needed equipment are examples of which term? 

a.  

Indirect care 

b.  

Direct care 

c.  

Referrals 

d.  

Delegation

ANS:  A 

 

Indirect care includes nursing interventions that are performed to benefit patients but do not

involve face-to-face contact with patients. Examples of indirect care include making the 

change-of-shift report, communicating and collaborating with members of the

interdisciplinary health care team, and ensuring availability of needed equipment. Direct care

refers to interventions that are carried out by having personal contact with patients. For

example, direct-care interventions include cleaning an incision, administering an injection,

ambulating with a patient, and completing patient teaching at the bedside. Referrals in health

care involve sending a patient to another member of the interdisciplinary health care team for

a consultation or other services. Delegation is the transfer of responsibility for performing a

task to another person while the nurse who delegated the task remains accountable. 

DIF:   Remembering                                     OBJ:   9.3                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination 

13.   The nurse correctly identifies which referral as an inappropriate nursing referral? 

a.  

Music therapist 

b.  

Community agencies 

c.  

Adaptive care services 

d.  

Dermatologist 

ANS:  D

 

 

 

 

 

 

 

 

 

 

 

 

A primary care provider (PCP) may refer a patient to a medical or surgical specialist for

further assessment, testing, or treatment. Nurses are often instrumental in initiating these types

of referrals but do not complete the actual referral. Referral to a community agency is usually

a collaborative action. Obtaining adaptive services and music therapy are independent nursing

actions. 

DIF:   Applying        OBJ:   9.3                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination 

14.   When implementing research-based interventions, the nurse realizes which concept? 

a.  

Implementing evidence-based care is unique to the nursing profession. 

b.  

Evidence-based practice is based entirely in nursing research. 

c.  

Evidence-based care is focused on practices and not outcomes. 

d.  

Nurses must read recent literature and remain current in practice. 

ANS:  D 

To implement research-based interventions, nurses must read recent literature and remain

current in practice. Implementation of evidence-based care is not unique to nursing; it

involves interventions provided by all members of the interdisciplinary health care team. The

best methods for treating patients with a variety of signs and symptoms are researched by

nurses with input from the research findings of other disciplines. Nursing care continues to

evolve as nursing research provides new knowledge and recognizes best practices to improve

patient care and outcomes. Evidence-based practice guidelines and updated information must

be included in plans of care. 

DIF:   Remembering                                     OBJ:   9.3                   TOP:  Implementation

 

MSC: NCLEX Client Needs C

NOT:  Concepts: Care Coordination

 

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ve Care Environment: Management of Care

 

15.   When the nurse is supportive and works of behalf of patients, this role is identified by which

term? 

a.  

Advocate 

b.  

Primary care provider 

c.  

Collaborator 

d.  

Delegator 

ANS:  A 

Nurses advocate by supporting and working on behalf of patients or persons for whom they

have concern. Nurses advocate for patients by coordinating care and supporting the changes

necessary to improve conditions and outcomes. Effective communication and collaboration

regarding patient care are essential for patient safety and positive patient outcomes. The

change-of-shift reports are an example. A PCP is usually a physician or advance practice

nurse. Delegation is the transfer of responsibility for performing a task to another person

while the nurse who delegated the task remains accountable. 

DIF:   Remembering                                     OBJ:   9.3                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  Concepts: Care Coordination 

16.   The nurse recognizes which task that cannot be delegated?

 

 

 

 

 

 

 

 

 

 

 

 

a.  

Obtaining vital signs 

b.  

Assessing lung sounds 

c.  

Bathing a patient 

d.  

Ambulating a patient 

ANS:  B 

Delegation is the transfer of responsibility for performing a task to another person while the

nurse who delegated the task remains accountable. Obtaining vital signs, bathing, and

ambulating are all tasks associated with the assessment part of the nursing process. The

nursing process cannot be delegated. 

DIF:   Analyzing       OBJ:   9.3                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination 

17.   The nurse identifies repositioning a patient, providing hygiene, and active listening as

examples of what concept? 

a.  

Dependent interventions 

b.  

Independent nursing interventions 

c.  

Standing orders 

d.  

Counseling 

ANS:  B 

Independent nursing interventions are tasks within the nurse’s scope of practice and do not

require an order from a physician. Dependent nursing interventions are tasks the nurse

undertakes that are within the nursing scope of practice but require the order of a primary care

provider to be implemented. Some physician orders are received through a preapproved 

standardized order set known

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ounseling is the process through which

individuals use professional guidance to address personal conflicts or emotional problems. 

T

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DIF:   Understanding                                    OBJ:   9.4                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Caregiving 

18.   The patient has an order for morphine sulfate 2 mg intravenously prn (as needed) every 2

hours. When the nurse administers this medication, which concept is being provided? 

a.  

Independent nursing intervention 

b.  

Dependent nursing intervention 

c.  

Referral 

d.  

Indirect care procedure 

ANS:  B 

Dependent nursing interventions are tasks that require an order from a physician or primary

care provider (PCP). Independent nursing interventions are tasks within the nursing scope of

practice that the nurse may undertake without a physician or PCP order. Referrals in health

care involve sending a patient to another member of the interdisciplinary health care team for

a consultation or other services. Indirect care includes nursing interventions that are

performed to benefit patients but do not involve face-to-face contact with patients. 

DIF:   Applying        OBJ:   9.5                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination

 

 

 

 

 

 

 

 

 

 

 

 

19.   The nurse understands which essential fact regarding documentation? 

a.  

It should be completed accurately and in a timely manner. 

b.  

It should not be computerized (EHR) because of disclosure risks. 

c.  

It is not a legal document although they can be helpful in lawsuits. 

d.  

It cannot be used in determining billing and reimbursement issues. 

ANS:  A 

All documentation entries should be completed in a timely, accurate, and professional manner.

Documentation most often is charted in the patient’s EHR and standardized flow sheets

according to agency policy. Patient health records are legal documents. Within the Health

Insurance Portability and Accountability Act (HIPAA) guidelines, patient documentation is

provided to insurance companies and others for billing and reimbursement. 

DIF:   Applying        OBJ:   9.7                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination 

20.   The nurse knows what fact to be the focus of evaluation, the final phase of the nursing

process? 

a.  

The focus is recording the care that was implemented. 

b.  

The focus is medical and nursing goals for the welfare of the patient. 

c.  

The focus is long-term goals only. 

d.  

The focus is patient responses to interventions and outcomes. 

ANS:  D 

Evaluation is the final step in the nursing process. Evaluation focuses on the patient and the

patient’s response to nursing

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ome attainment. Evaluation is not a record

of care that was implemented. Patient outcomes serve as the criteria against which the success

of a nursing intervention is judged. During the evaluation phase, nurses use critical thinking to 

determine whether a patient’s short- and long-term goals were met and whether desired

outcomes were achieved. Monitoring whether the patient’s goals were attained is

collaborative, involving the patient in the decision-making process. 

DIF:   Remembering                                     OBJ:   9.8                   TOP:  Evaluation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 

NOT:  Concepts: Care Coordination 

21.   When the nurse realizes that the patient’s short-term goals have not been met, the nurse

should carry out which task? 

a.  

Revise or adapt the plan of care. 

b.  

Assume that the patient did not want to achieve his goals. 

c.  

Understand that a plan of care is almost never changed. 

d.  

Reassess plans of care only after major patient–nurse interactions. 

ANS:  A

 

 

 

 

 

 

 

 

 

 

 

 

When a patient goal is unmet or only partially met, the plan of care may need to be revised or

adapted to support goal attainment. There are many reasons why goals are not met, including

changes in the patient condition, unrealistic goals, or inappropriate interventions that do not

help meet the goal. It is common for plans of care to change to meet evolving needs.

Reassessment occurs with each patient–nurse interaction. As changes in a patient’s condition

occur, the plan of care should be revised. 

DIF:   Applying        OBJ:   9.8                   TOP:  Evaluation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination 

22.   The nurse identifies that the nursing process is an attempt to meet patient needs, including

which concept? 

a.  

Nursing process is linear in nature. 

b.  

Nursing process is dynamic and cyclic. 

c.  

Nursing process requires occasional care plan re-evaluation. 

d.  

Nursing process does not allow care plan modification. 

ANS:  B 

The nursing process is ongoing in an attempt to meet patient needs. The nursing process is not

linear in nature but is dynamic and cyclic, constantly adapting to a patient’s health status. Care

plan modifications may be necessitated due to deterioration or improvement of a patient’s

condition. The Joint Commission requires patient care plans to be evaluated on a continual

basis. 

DIF:   Understanding                                    OBJ:   9.9                   TOP:  Evaluation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

 

NOT:  Concepts: Care Coordin

MULTIPLE RESPONSE 

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1.   The nurse recognizes which interventions to be prevention oriented? (Select all that apply.) 

a.  

Immunization programs 

b.  

Cleansing an incision 

c.  

Cardiac risk factor modification 

d.  

Placing infants prone when they sleep 

e.  

Teaching patients to ask their providers to wash their hands 

ANS:  A, B, C, D, E 

Some interventions prevent illness or complications and promote healthy activities or

lifestyles. Interventions such as patient education and immunization programs are prevention

oriented. Cleansing an incision is a nursing intervention that can help prevent infection.

Educating a patient about risk-factor modification for cardiovascular disease may prevent a

future myocardial infarction. Placing infants on their backs to sleep may reduce the risk of

sudden infant death syndrome. Patients should be instructed to ask their care providers to

wash their hands if they have not observed them doing so. 

DIF:   Remembering                                     OBJ:   9.3                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 

NOT:  Concepts: Caregiving

 

 

 

 

 

 

 

 

2.   The nurse considers which skills to be invasive procedures? (Select all that apply.) 

a.  

Administering oral medications 

b.  

Starting an intravenous (IV) line 

c.  

Repositioning the patient 

d.  

Inserting a urinary catheter 

ANS:  B, D 

Many interventions focus on physical care that is performed when treating patients. These

interventions may include invasive procedures, such as starting an intravenous line or

inserting a catheter, or they may be noninvasive, such as administering oral medications and

repositioning. 

DIF:   Evaluating      OBJ:   9.2                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection 

Control                       NOT:  Concepts: Caregiving 

3.   The nurse understands that the five rights of delegation include which components? (Select all

that apply.) 

a.  

Right patient 

b.  

Right time 

c.  

Right person 

d.  

Right supervision 

e.  

Right task 

ANS:  C, D, E 

Delegation principles focus on the appropriate intervention (task) being performed under the

correct circumstances, by the correct personnel, and with the correct direction and 

supervision. The right patien

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medication administration.

 

 

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er to components of the “6 Rights” of

 

O

DIF:   Understanding                                    OBJ:   9.3                   TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Caregiving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chapter 10: Documentation, Electronic Health Records, and Reporting

Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative 

Practice,  

MULTIPLE CHOICE 

1.   The nurse understands the need for accurate documentation due to which fact? 

a.  

Accurate documentation is needed for proper reimbursement. 

b.  

Accurate documentation must be electronically generated. 

c.  

Accurate documentation does not include e-mails or faxes. 

d.  

Accurate documentation is only accepted in court if written by hand. 

ANS:  A 

Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic-

related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care

documentation is any written or electronically generated information about a patient that

describes the patient, the patient’s health, and the care and services provided, including the

dates of care. These records may be paper or electronic documents, such as electronic medical

records, faxes, e-mails, audiotapes, videotapes, and images. All such records are considered

legal documentation and may be used in court. 

DIF:   Remembering                                     OBJ:   10.1                 TOP:  Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication 

2.   The nurse identifies which statement to be true regarding nursing documentation? 

a.  

Standards for documentation are established by a national commission. 

b.  

Medical records should be accessible to everyone. 

c.  

Documentation should not include the patient’s diagnosis. 

d.  

High-quality nursing documentation reflects the nursing process. 

ANS:  D 

The ANA’s model for high-quality nursing documentation reflects the nursing process and

includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and

retrievability. Standards for documentation are established by each health care organization’s

policies and procedures. They should be in agreement with The Joint Commission’s standards

and elements of performance, including having a medical record for each patient that is

accessed only by authorized personnel. General principles of medical record documentation

from the Centers for Medicare and Medicaid Services (2017) include the need for

completeness and legibility; the reasons for each patient encounter, including assessments and

diagnosis; and the plan of care, the patient’s progress, and any changes in diagnosis and

treatment. 

DIF:   Understanding                                    OBJ:   10.1                 TOP:  Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 

NOT:  Concepts: Communication 

3.   The nurse identifies which true statement regarding the medical record? 

a.  

It serves as a major communication tool but is not a legal document. 

b.  

It cannot be used to assess quality of care issues.

 

 

 

 

 

 

 

 

 

 

 

 

c.  

It is not used to determine reimbursement claims. 

d.  

It can be used as a tool for biomedical research and provide education. 

ANS:  D 

The medical record promotes continuity of care and ensures that patients receive appropriate

health care services. The record can be used to assess quality-of-care measures, determine the

medical necessity of health care services, support reimbursement claims, and protect health

care providers, patients, and others in legal matters. It is a clinical data archive. The medical

record serves as a tool for biomedical research and provider education, collection of statistical

data for government and other agencies, maintenance of compliance with external regulatory

bodies, and establishment of policies and regulations for standards of care. The record serves

as the major communication tool between staff members and as a single data access point for

everyone involved in the patient’s care. It is a legal document that must meet guidelines for

completeness, accuracy, timeliness, accessibility, and authenticity. The record can be used to

assess quality-of-care measures, determine the medical necessity of health care services,

support reimbursement claims, and protect health care providers, patients, and others in legal

matters. 

DIF:   Understanding                                    OBJ:   10.2                 TOP:  Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 

NOT:  Concepts: Communication 

4.   The nurse knows that paper records are being replaced by other forms of record keeping for

what reason? 

a.  

Paper is fragile and susceptible to damage. 

b.  

Paper records are always available to multiple people at a time. 

c.  

Paper records can be stored without difficulty and are easily retrievable. 

d.  

Paper records are permanent and last indefinitely. 

ANS:  A 

Paper records have several potential problems. Paper is fragile, susceptible to damage, and can

degrade over time. It may be difficult to locate a particular chart because it is being used by

someone else, it is in a different department, or it is misfiled. Storage and control of paper

records can be a major problem. 

DIF:   Evaluating      OBJ:   10.2                 TOP:  Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication 

5.   When the nurse is charting in the paper medical record, what action does the nurse carry out? 

a.  

Print his/her name since signatures are often not readable. 

b.  

Omit nursing credentials since only the nurses chart 

c.  

Skip a line between entries so that it looks neat. 

d.  

Use black ink unless the facility allows a different color. 

ANS:  D 

Entries into paper medical records are traditionally made with black ink to enable copying or

scanning, unless a facility requires or allows a different color. The date, time, and signature,

with credentials of the person writing the entry, are included in the entry. No blank spaces are

left between entries because they could allow someone to add a note out of sequence. 

DIF:   Remembering                                     OBJ:   10.3                 TOP:  Implementation

 

 

 

 

 

 

 

 

 

 

 

 

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication 

6.   The nurse is admitting a patient who has had several previous admissions. To obtain a

knowledge base about the patient’s medical history, the nurse would access which document? 

a.  

Electronic medical record (EMR) 

b.  

The computerized provider order entry (CPOE) 

c.  

Electronic health record (EHR) 

d.  

Primary provider’s office notes 

ANS:  C 

The EHR is a longitudinal record of health that includes the information from inpatient and

outpatient episodes of health care from one or more care settings. The EMR is a record of one

episode of care, such as an inpatient stay or an outpatient appointment. CPOE allows

clinicians to enter orders in a computer that are sent directly to the appropriate department. It

does not provide historical data. The primary provider’s office notes may not include all the

patient’s information if the patient has other providers. 

DIF:   Applying        OBJ:   10.2                 TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication 

7.   The nurse understands which statement about the use of electronic health records is true? 

a.  

They improve patient health status. 

b.  

They require a keyboard to enter data. 

c.  

They have not reduced medication errors. 

d.  

They require increased storage space. 

ANS:  A 

Adoption of an EHR system produces major cost savings through gains in productivity and

error reduction, which ultimately improves patient health status. The most common benefits of

electronic records are increased delivery of guideline-based care, better monitoring, reduced

medication errors, and decreased use of care. Use of EHRs can reduce storage space, allow

simultaneous access by multiple users, facilitate easy duplication for sharing or backup, and

increase portability in environments using wireless systems and hand-held devices. Although

data are often entered by keyboard, they can also be entered by means of dictated voice

recordings, light pens, or handwriting and pattern recognition systems. 

DIF:   Remembering                                     OBJ:   10.2                 TOP:  Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication 

8.   The nurse is caring for patients on a unit that uses electronic health records (EHRs). What 

action by the nurse protects personal health information? 

a.  

The nurse should allow only nurses that he/she knows and trusts to use his/her

verification code. 

b.  

The nurse should not worry about mistakes since the information cannot be

tracked. 

c.  

The nurse should never share any password with anyone. 

d.  

The nurse should be aware that the EHR is sophisticated and immune to failure. 

ANS:  C

 

 

 

 

 

 

 

 

 

 

 

 

Access to an EHR is controlled through assignment of individual passwords and verification

codes that identify people who have the right to enter the record. Passwords and verification

codes should never be shared with anyone. Health care information systems have the ability to

track who uses the system and which records are accessed. These organizational tools

contribute to the protection of personal health information. Disadvantages of use of computers

for documentation include computer and software failure and problems if there is a power

outage. 

DIF:   Applying        OBJ:   10.4                 TOP:  Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication 

9.   The nurse recognizes which statement to be accurate regarding what should be documented? 

a.  

Document facts and subjective data from the patient. 

b.  

Document how he/she feels about the care being provided. 

c.  

Document in a “block” fashion once per shift. 

d.  

Double document as often as possible in order to not miss anything. 

ANS:  A 

Nursing documentation is an important part of effective communication among nurses and

with other health care providers. Documentation should be factual and nonjudgmental, with

proper spelling and grammar. Subjective data from the patient should be included. Events

should be reported in the order they happened, and documentation should occur as soon as

possible after assessment, interventions, condition changes, or evaluation. Each entry includes

the date, time, and signature with credentials of the person documenting. Double

documentation of data should be avoided because legal issues can arise as a result of

conflicting data. 

DIF:   Remembering                                     OBJ:   10.3                 TOP:  Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 

NOT:  Concepts: Communication 

10.   The nurse recognizes that nursing documentation is guided by what process? 

a.  

The nursing process 

b.  

NANDA-I, nursing diagnoses 

c.  

Nursing interventions classification 

d.  

Nursing Outcomes Classification 

ANS:  A 

Nursing documentation is guided by the five steps of the nursing process: assessment,

diagnosis, planning, implementation, and evaluation. Standardized nursing terminologies such

as the North American Nursing Diagnosis Association–International (NANDA-I) Nursing

Diagnoses, nursing interventions classification (NIC), and Nursing Outcomes Classification

(NOC) may be used in the documentation process. 

DIF:   Remembering                                     OBJ:   10.3                 TOP:  Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication 

11.   What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation? 

a.  

They are chronologic.