Nursing Documentation, Care Planning, and Patient Safety: Key Concepts and Methods

A nurse documents care using Data, Action, and Response (DAR). Which documentation method is being used?

A. SOAP documentation

B. Problem-oriented medical record

C. PIE charting

D. Focus charting

D. Focus charting

Which component of Focus charting describes nursing interventions?

A. Data

B. Action

C. Response

D. Evaluation

B. Action

Which documentation system organizes information using Problem, Intervention, and Evaluation?

A. SOAP

B. Focus charting

C. PIE charting

D. Charting by exception

C. PIE charting

Which is a disadvantage of charting by exception?

A. Increased charting time

B. Redundant documentation

C. Missing details if norms are unclear

D. Inability to document abnormalities

C. Missing details if norms are unclear

Which section of SOAP documentation includes vital signs and lab values?

A. Subjective

B. Objective

C. Assessment

D. Plan

B. Objective

In the ISBARQ handoff method, which step allows clarification?

A. Identify

B. Situation

C. Recommendation

D. Questions

D. Questions

Which safety practice is required by The Joint Commission?

A. Time-out before procedures only

B. Three patient identifiers

C. Two patient identifiers

D. RN verification only

C. Two patient identifiers

Which nursing action best supports continuity of care during a transfer?

A. Giving verbal report only

B. Using ISBARQ for handoff

C. Sending the chart later

D. Minimizing documentation

B. Using ISBARQ for handoff

What is the primary role of a hospitalist?

A. Provide outpatient care

B. Manage inpatient care

C. Perform surgeries

D. Replace primary care providers

B. Manage inpatient care

Which focus best reflects today's health care priorities?

A. Acute care treatment

B. Disease cure only

C. Health promotion and prevention

D. Physician-directed care

C. Health promotion and prevention

Which nursing action best supports health care reform?

A. Delegating all care

B. Avoiding policy involvement

C. Advocating for patients

D. Limiting interdisciplinary work

C. Advocating for patients

Holistic nursing care focuses on:

A. Physical symptoms only

B. The disease process

C. The whole person

D. Medical treatment plans

C. The whole person

A period of worsening symptoms in a chronic illness is called:

A. Remission

B. Exacerbation

C. Recovery

D. Relapse

B. Exacerbation

Promoting human dignity requires nurses to:

A. Control decision-making

B. Use medical terminology only

C. Respect patient autonomy

D. Avoid patient involvement

C. Respect patient autonomy

Which need has the highest priority according to Maslow?

A. Safety

B. Love and belonging

C. Self-esteem

D. Physiologic

D. Physiologic

Which is an example of primary prevention?

A. Mammography

B. Rehabilitation therapy

C. Immunizations

D. Physical therapy

C. Immunizations

Blood pressure screening programs are an example of:

A. Primary prevention

B. Secondary prevention

C. Tertiary prevention

D. Restorative care

B. Secondary prevention

Rehabilitation after a stroke is considered:

A. Primary prevention

B. Secondary prevention

C. Tertiary prevention

D. Health promotion

C. Tertiary prevention

Disability is best defined as:

A. A medical diagnosis

B. A disease condition

C. A limitation in functioning

D. An acute illness

C. A limitation in functioning

Which condition is a cognitive disability?

A. Down syndrome

B. Dementia

C. Spina bifida

D. Cerebral palsy

B. Dementia

Which is an example of an intellectual disability?

A. ADHD

B. Traumatic brain injury

C. Down syndrome

D. Stroke

C. Down syndrome

What differentiates disability from a disabling disorder?

A. Disability is temporary

B. Disorders are always genetic

C. Disability reflects functional impact

D. Disorders do not affect function

C. Disability reflects functional impact

Which is a barrier to health care access?

A. Health literacy

B. Cultural competence

C. Provider bias

D. Preventive care

C. Provider bias

Why should nurses use people-first language?

A. It shortens documentation

B. It reduces stigma

C. It emphasizes diagnosis

D. It meets billing requirements

B. It reduces stigma

Patients with multiple chronic conditions are at higher risk for:

A. Improved outcomes

B. Medication complications

C. Reduced health care use

D. Faster recovery

B. Medication complications

Which problem-solving method relies on past experience and intuition?

A. Trial-and-error

B. Critical thinking

C. Clinical reasoning

D. Intuition

D. Intuition

Which method uses a structured step-by-step approach?

A. Intuition

B. Trial-and-error

C. Nursing process

D. Guessing

C. Nursing process

Person-centered care emphasizes:

A. Provider authority

B. Patient partnership

C. Task completion

D. Institutional policies

B. Patient partnership

Clinical reasoning primarily involves:

A. Memorization

B. Task completion

C. Pattern recognition

D. Guessing

C. Pattern recognition

Which is a professional nursing attribute?

A. Efficiency

B. Accountability

C. Technical skill only

D. Independence

B. Accountability

Which QSEN competency focuses on minimizing harm?

A. Informatics

B. Quality improvement

C. Safety

D. Evidence-based practice

C. Safety

Which QSEN competency emphasizes effective teamwork?

A. Patient-centered care

B. Informatics

C. Teamwork and collaboration

D. Safety

C. Teamwork and collaboration

Timely documentation means charting:

A. At the end of the shift

B. Within 24 hours

C. As soon as care is provided

D. After discharge

C. As soon as care is provided

Which documentation principle avoids bias?

A. Detailed charting

B. Timely charting

C. Nonjudgmental language

D. Narrative notes

C. Nonjudgmental language

Focus charting is best used when documenting:

A. Routine vitals

B. A specific patient concern

C. Shift summaries

D. Intake and output

B. A specific patient concern

Which PIE component evaluates outcomes?

A. Problem

B. Intervention

C. Evaluation

D. Planning

C. Evaluation

Which SBAR component includes patient history?

A. Situation

B. Background

C. Assessment

D. Recommendation

B. Background

Which is required when taking a telephone order?

A. Written signature immediately

B. Provider presence

C. Read-back verification

D. Verbal agreement only

C. Read-back verification

The primary purpose of assessment is to:

A. Diagnose disease

B. Establish baseline data

C. Implement care

D. Evaluate outcomes

B. Establish baseline data

Which is subjective data?

A. Blood pressure

B. Temperature

C. Pain report

D. Lab values

C. Pain report

Which is objective data?

A. Anxiety

B. Nausea

C. Temperature

D. Fatigue

C. Temperature

Which data collection method involves direct patient questioning?

A. Observation

B. Physical exam

C. Interview

D. Documentation review

C. Interview

Why are privacy and confidentiality essential?

A. Reduce workload

B. Meet billing needs

C. Protect patient rights

D. Improve efficiency

C. Protect patient rights

A nursing diagnosis focuses on:

A. Disease pathology

B. Provider orders

C. Patient responses

D. Diagnostic tests

C. Patient responses

Which is a risk nursing diagnosis?

A. Acute pain

B. Impaired mobility

C. Risk for infection

D. Ineffective airway clearance

C. Risk for infection

Which part of a nursing diagnosis lists signs and symptoms?

A. Etiology

B. Problem

C. Defining characteristics

D. Risk factors

C. Defining characteristics

During planning, the nurse develops:

A. Medical diagnoses

B. Physician orders

C. Measurable outcomes

D. Discharge summaries

C. Measurable outcomes

Which is an independent nursing intervention?

A. Administering IV antibiotics

B. Repositioning the patient

C. Adjusting ventilator settings

D. Prescribing medication

B. Repositioning the patient

Which is an example of indirect nursing care?

A. Bathing the patient

B. Administering medication

C. Communicating with the care team

D. Ambulation assistance

C. Communicating with the care team

The evaluation phase determines whether:

A. Orders were followed

B. Outcomes were met

C. Diagnoses were correct

D. Documentation was complete

B. Outcomes were met

Which statement best describes the primary focus of the healthcare delivery system?

A. Treat acute illness only

B. Reduce healthcare costs

C. Promote, maintain, and restore health across the lifespan

D. Provide services only in hospitals

C. Promote, maintain, and restore health across the lifespan

Which goal is included in the IHI Quadruple Aim?

A. Increase nurse productivity

B. Improve patient experience

C. Limit access to care

D. Focus on acute care only

B. Improve patient experience

Which action best promotes quality healthcare?

A. Following tradition

B. Reducing documentation

C. Using evidence-based practice

D. Limiting staff education

C. Using evidence-based practice

Which reimbursement model focuses on patient outcomes?

A. Fee-for-service

B. Private insurance

C. Value-based reimbursement

D. Out-of-pocket payment

C. Value-based reimbursement

Healthcare complexity has increased primarily due to:

A. Fewer chronic illnesses

B. Aging population and advanced technology

C. Reduced regulation

D. Decreased specialization

B. Aging population and advanced technology

Which team member coordinates care and manages patient education?

A. UAP

B. Registered nurse

C. Respiratory therapist

D. Dietitian

B. Registered nurse

Which responsibility belongs to the community-based nurse?

A. Performing invasive procedures

B. Coordinating community resources

C. Diagnosing disease

D. Managing hospital staffing

B. Coordinating community resources

Continuity of care is best defined as:

A. Care provided by one provider

B. Care limited to hospitals

C. Coordinated care across time and settings

D. Task-oriented nursing

C. Coordinated care across time and settings

Which communication tool improves patient safety during handoffs?

A. SOAP

B. PIE

C. ISBAR

D. Narrative notes

C. ISBAR

Which goal is part of Joint Commission National Patient Safety Goals?

A. Increase reimbursement

B. Improve patient identification accuracy

C. Reduce staffing costs

D. Limit documentation

B. Improve patient identification accuracy

Discharge planning primarily focuses on:

A. Ending care

B. Completing paperwork

C. Safe transition to next level of care

D. Reducing length of stay

C. Safe transition to next level of care

Health is defined as:

A. Absence of disease

B. Physical wellness only

C. A dynamic state of well-being

D. Lack of symptoms

C. A dynamic state of well-being

Which need must be met first according to Maslow?

A. Love and belonging

B. Safety

C. Physiologic needs

D. Self-esteem

C. Physiologic needs

Health disparities result primarily from:

A. Genetics

B. Patient choices only

C. Social and economic disadvantage

D. Provider bias alone

C. Social and economic disadvantage

Social determinants of health include:

A. Lab results

B. Medication adherence

C. Housing and employment

D. Disease severity

C. Housing and employment

Which is an example of primary prevention?

A. Colonoscopy

B. Immunizations

C. Cardiac rehab

D. Disease management

B. Immunizations

Secondary prevention focuses on:

A. Preventing disease onset

B. Early detection and treatment

C. Rehabilitation

D. Lifestyle modification

B. Early detection and treatment

Tertiary prevention aims to:

A. Prevent illness

B. Screen for disease

C. Reduce complications

D. Promote wellness

C. Reduce complications

Which is a characteristic of chronic illness?

A. Short duration

B. Reversible

C. Requires ongoing management

D. Minimal lifestyle impact

C. Requires ongoing management

Why are chronic illnesses increasing?

A. Reduced healthcare access

B. Aging population and lifestyle factors

C. Decreased life expectancy

D. Improved prevention

B. Aging population and lifestyle factors

Which is a modifiable risk factor?

A. Age

B. Genetics

C. Smoking

D. Sex

C. Smoking

Which is an unmodifiable risk factor?

A. Diet

B. Exercise

C. Age

D. Smoking

C. Age

Which term best reflects respectful language?

A. Diabetic patient

B. Stroke victim

C. Person with diabetes

D. Disabled person

C. Person with diabetes

Blended competencies integrate:

A. Policies and procedures

B. Knowledge, skills, and attitudes

C. Documentation systems

D. Staffing models

B. Knowledge, skills, and attitudes

Which QSEN competency focuses on preventing harm?

A. Informatics

B. Safety

C. Teamwork

D. Quality improvement

B. Safety

Reflective practice allows nurses to:

A. Avoid mistakes

B. Improve future care

C. Reduce workload

D. Delegate responsibility

B. Improve future care

Which is a primary reason for documentation?

A. Increase charting time

B. Provide legal evidence

C. Replace verbal communication

D. Reduce patient care

B. Provide legal evidence

Which guideline improves legal safety in documentation?

A. Timely and factual charting

B. Narrative charting

C. Use of abbreviations

D. Delayed documentation

A. Timely and factual charting

Which documentation method uses DAR?

A. SOAP

B. PIE

C. Focus charting

D. Narrative

C. Focus charting

Problem-oriented documentation is organized by:

A. Discipline

B. Time

C. Patient problems

D. Provider preference

C. Patient problems

Telephone orders require:

A. Nurse documentation only

B. Immediate execution

C. Read-back verification

D. Delayed signing

C. Read-back verification

Incident reports are:

A. Part of the medical record

B. Used for punishment

C. Quality improvement tools

D. Shared with patients

C. Quality improvement tools

What is the first step of the nursing process?

A. Diagnosis

B. Planning

C. Assessment

D. Evaluation

C. Assessment

Which data are subjective?

A. Blood pressure

B. Pain rating

C. Oxygen saturation

D. Lab results

B. Pain rating

Objective data are:

A. Patient feelings

B. Measurable findings

C. Patient opinions

D. Symptoms only

B. Measurable findings

Validation involves:

A. Recording data

B. Confirming data accuracy

C. Diagnosing illness

D. Planning care

B. Confirming data accuracy

A nursing diagnosis focuses on:

A. Disease pathology

B. Patient responses

C. Medical treatment

D. Diagnostic tests

B. Patient responses

Which diagnosis format includes problem, cause, and evidence?

A. SOAP

B. PIE

C. PES

D. DAR

C. PES

Which diagnosis identifies potential problems?

A. Actual diagnosis

B. Medical diagnosis

C. Risk diagnosis

D. Wellness diagnosis

C. Risk diagnosis

Which intervention is nurse-initiated?

A. Administering IV antibiotics

B. Ordering lab tests

C. Repositioning a patient

D. Prescribing medication

C. Repositioning a patient

Which intervention requires a provider order?

A. Patient education

B. Ambulation

C. Medication administration

D. Turning schedules

C. Medication administration

Direct care includes:

A. Chart review

B. Team meetings

C. Wound care

D. Discharge planning

C. Wound care

Indirect care includes:

A. Bathing the patient

B. Medication administration

C. Coordinating care

D. Ambulation

C. Coordinating care

Evaluation determines whether:

A. Interventions were implemented

B. Outcomes were achieved

C. Diagnoses were correct

D. Care was documented

B. Outcomes were achieved

Which outcome indicates successful care?

A. Goal partially met

B. Goal not met

C. Goal met

D. Goal revised

C. Goal met