- | P a g e
NSRG 91 FINAL NEWEST 2025 ACTUAL EXAM
COMPLETE 150 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+
What are the common parts of a healthcare record? - ANSWER- Patient identification, informed consent for treatments, medical diagnosis and progress notes, doctors' orders, nursing database, operative record, discharge plan, and summary.
What terms should not be used in documentation? - ANSWER- Terms like 'seems', 'appears', 'apparently', 'small', 'large', 'usual day', 'good night', 'nice man', 'difficult patient' should be avoided.
What must every entry in documentation have? - ANSWER- Date, time, full signature, and correct titles. Only chart care that you have provided.
How should other patients be referred to in documentation? - ANSWER-Instead of using their names, refer to them as 'patient's room mate'.
- / 3
- | P a g e
What are the CNO practice standards in regards to documentation? - ANSWER-Communication, Accountability, Security
Communication? - ANSWER-Reflects all aspects of the nursing process, legible, permanent ink, full signature, and designations.
Accountability? - ANSWER-:Never delete, alter, or modify
another nurse's charts.
Security? - ANSWER-Maintain confidentiality, access only info needed for care, use a secure line to fax or email patient info.
What is POMR? - ANSWER-Problem-Oriented Medical Record.
What does PIE stand for? - ANSWER-Problem, Intervention, Evaluation.
What does APIE stand for? - ANSWER-Assessment, Problem, Intervention, Evaluation.
- / 3
- | P a g e
What does SOAP stand for? - ANSWER-Subjective, Objective, Assessment, Plan.
What does SOAPIE or SOAPIER stand for? - ANSWER- Subjective, Objective, Assessment, Plan, Intervention, Evaluation, (Revision/Recommendation).
What is Focus Charting (DAR)? - ANSWER-Data, Action, Response.
What is Charting by Exception? - ANSWER-Recording only abnormal or significant data.
What is a Kardex? - ANSWER-A quick reference with the patient's summary of basic information.
What are Critical Pathways or Care Maps? - ANSWER-Pre- printed documents with specific goals, interventions, and time frames. (e.g., pneumonia patient expected to have a 4 day stay)
What are standardized nursing care plans? - ANSWER-Pre- printed established care plans that should be modified based on the individual's needs.
- / 3