Nursing Documentation and Healthcare Practice Test

These questions are part of the practice quiz. Start practicing

• TO and VO stand for what?
• Which charting approach organizes notes around problems, interventions, and evaluations?
• Which term lists Florence Nightingale, Clara Barton, and Lillian D. as historical nursing figures?
• What term refers to the elements that make nursing a profession?
• Which nursing role focuses on teaching and preparing future nurses?
• In Focus Charting, which component captures measurable data, such as vital signs?
• When abbreviations are used in documentation, which is appropriate?
• Before performing any invasive procedure, which documentation steps should a nurse complete?
• Which term is used to describe the expenses and economic factors in healthcare?
• The rule 'You may not do a procedure under supervision as a nursing student that you are not authorized to do as an aide or PCT' is best described by which concept?
• SBAR is a structured communication tool used in healthcare. What does SBAR stand for?
• Which concept provides guidelines for effective delegation and risk management?
• What is the abbreviation for the Texas Board of Nursing?
• Which description best captures the core definition of nursing?
• Which topic focuses on disaster preparedness, early identification of threats, and modern nursing readiness in the 21st century?
• Which term aligns with 'Always follow standards of care set forth by governing bodies'?
• Current issues and trends in health care delivery include which of the following?
• A nurse demonstrates how to use an insulin syringe to a newly diagnosed diabetic patient. Which nursing role is this?
• Acuity Rating Systems are based on what?
• Which term describes actions to prevent issues that must be reported to outside agencies?
• What term describes the level of care a patient requires?
• The ANA Scope of Nursing Practice defines which of the following?
• Which of the following is NOT listed as a role of the professional nurse?
• Which statement aligns with best practice in documenting preoperative patient care?
• The National League for Nursing implements its mission guided by four core values that permeate its work. This describes which organization?
• Before leaving for the operating room, why is it common to ask a patient to void?
• Which term describes the professional development path that includes Nurse Practitioner and Clinical Nurse Specialist roles within advanced nursing degrees?
• Which of the following actions demonstrates patient-centered care in preoperative planning?
• Which organization provides the Standards of Nursing Practice?
• Which of the following is a role of the professional nurse?
• Current documentation should include which of the following elements?
• A role for nurses who manage healthcare facilities or departments is called?
• Which organization brings together and mentors new nurses, conveys ethics and standards of practice, promotes development of skills, and advocates for the profession?
• Which statement about read-back of orders is true?
• Who conducts studies to advance the field of nursing?
• Which level of care is focused on restoration and rehabilitation after acute illness?
• Which factor is included in the rise of healthcare costs (medications, technology, administrative costs, chronic disease, legal factors)?
• Which item is emphasized as part of confidentiality in documentation?
• Charting by Exception primarily documents which type of information?
• Which information must be included when documenting a telephone or verbal order?
• Which statement best describes Charting by Exception?
• Which discipline integrates nursing science, computer science, and information science to manage and communicate data in nursing practice?
• What term describes the defining of the legal scope of practice for nurses?
• Which organization is dedicated to advancing the health of the nation by promoting excellence in nursing education and a diverse workforce?
• Which nurse develops theories to explain nursing phenomena?
• Which statement best describes nurses' self-care?
• Which Texas organization is a private association representing nurses and advocates for practice issues?
• The scope of nursing practice defines which of the following?
• Obtaining the patient's signature on the surgical informed consent is best described as which document?
• Which organization promotes excellence in nursing education to build a strong and diverse nursing workforce to advance health locally and globally?
• Which term corresponds to 'Always practice within your scope as a registered nurse'?
• Which term describes nursing work patterns such as primary nursing, functional nursing, and team nursing?
• Which concept emphasizes communicating effectively with the care team to prevent errors?
• Which statement best captures the scope of nursing responsibilities?
• Empowered by the Texas Legislature to protect the public, regulate the practice of vocational, professional, and advanced practice nursing, issue licenses, and assure that minimum standards of safe practice are met.
• Which topic reflects advancements in nursing informatics and technology, along with improvements in disaster preparedness and the Affordable Care Act?
• What should you do to ensure accuracy of a telephone order?
• As a nursing student you are ALWAYS under the supervision of your instructor, even if she is not physically present, which concept does this describe?
• Which statement describes the information included when documenting a telephone order?
• What is the purpose of Quality Improvement (QI) in a healthcare organization?
• Which term describes actions that are within the legal scope of nursing practice for a student nurse?
• Which organization focuses on nursing education and research and credentialing?
• Which practice involves repeating orders back to the clinician to verify accuracy?
• Which statement reflects an element emphasized in professional nursing standards?
• When transporting a patient to the operating room, what is essential to document?
• Which term is associated with evaluating and improving care quality through patient feedback and outcomes?
• The National Student Nurse Association primarily serves which group?
• Transferring authority or responsibility to competent member of the healthcare team.
• Educational Pathways describe the educational routes for professional nursing practice. Which term matches this description?
• Which nurse focuses on ethical issues in healthcare and nursing practice?
• Which category covers Review off Orders, Call HCP in event additional Orders are needed, SBAR, Read Back, Read New Orders to Team, Documentation in Chart if Time Permits.
• Which degree path prepares nurses for advanced practice roles such as Nurse Practitioner and Clinical Nurse Specialist?
• Which of these is a common element in nursing documentation about patient assistance?
• Which entries are included in complete documentation?
• A patient who needs nursing care and rehabilitation following a stroke would most benefit from receiving care at which setting?
• Who is commonly assigned to determine whether a patient understands preoperative preparation?
• Which factor is a primary driver of healthcare cost?
• Which level of care focuses on restoration and rehabilitation after illness or injury?
• Which organization defines the various roles of the professional nurse?
• Which term refers to the combination of warmth, compassion, and evidence-based practice in nursing?
• Which term best describes helping a patient with daily activities such as toileting and hygiene in a clinical setting?
• What is used to determine hours of care and the number of staff required for a group of patients per shift or per 24 hours?
• Which term describes an ongoing, data-driven effort to improve processes and outcomes within healthcare organizations?
• In PIE, what is the correct order of components?
• In preoperative routines, the phrase 'patient assistance' most closely equals which nursing function?
• Which nurse has advanced expertise in a specific area of clinical practice?
• Individuals prepared through doctoral degrees in nursing to take on leadership roles in healthcare are described as?
• Which role would focus on creating and explaining nursing theories?
• When a patient refuses a treatment, what is the appropriate documentation?
• Which nursing care model emphasizes individualized patient care and can be more costly?
• Registered Nurses (RN) and Advanced Practice Registered Nurses (APRN) comprise the 'who' constituency and have been educated, titled, and maintain active licensure to practice nursing.
• Which process is designed to reduce the risk of errors affecting patients?
• Which policy governs safe delegation and accountability in nursing practice?
• The phrase "four dynamic and integrated core values" applies to which organization?
• Which statement describes a professional nurse who delivers safe high-quality evidence-based care using critical thinking and is accountable for themselves, their patient, and their peers?
• What category describes the steps: First Check MAR... Second Check, Prepare Med, Third Check with Patient Teaching & Barcode scanning, Chart Medication?
• Which statement correctly describes the scope of nursing practice?
• Which concept emphasizes delivering care with warmth, compassion, and respect, grounded in evolving evidence-based practice?
• Which organization represents the professional student branch of nursing?
• What does TORB stand for?
• Documentation that notes the support provided to a patient with activities of daily living is best categorized as:
• Which term encompasses the variety of healthcare settings and services, including continuity of care?
• Which activity improves the nurse's status with the health team members?
• A way of preventing errors or defects in manufactured products and avoiding problems when delivering solutions or services to customers.
• Which item is described by 'Under the right supervision and evaluation'?
• Which care delivery model facilitates communication among staff and improves work satisfaction but can lead to lost time during shift reports?
• What is a character trait of a nurse as defined by the American Nurses Association?
• Which statement best describes the expected quality of nursing documentation?
• Which term describes the framework for delivering care, coordinating services, and working with the healthcare team to improve outcomes while controlling costs?
• Which term refers to improving how patients fare as a result of care?
• Which set of measures focuses on patient experiences during hospital stays and can influence hospital ratings?
• Which phrase best describes delivering the highest standard of care for a patient?
• Which category includes Bathing or shower, dressing, toileting, getting out of bed to chair, walking, and eating?
• What term describes a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health record?
• Which concept emphasizes practicing within one's scope and collaborating with the healthcare team to improve outcomes and control costs?
• An organization-wide approach to continuous improvement that focuses on customer satisfaction.
• Which documentation practice supports legal protection for nurses?
• The professional care of patients, especially in a hospital.
• Which framework describes five levels of proficiency from Novice to Expert?
• Which action is performed to document medication administration in the chart after giving the medication?
• Private organizations that represent their members, with membership dues paid, can be local, state, national, or international, lead the way in nursing practice issues, and provide a united voice for legislative/political matters.
• Which communication framework is used to structure information during handoffs or clarifying orders?
• Which entity's mission is to protect and promote the welfare of the people of Texas by ensuring nursing licensure competency?
• Which statement best describes an element of the ANA Standards of Nursing Practice?
• Which item is not typically required to be documented in preoperative preparation?
• Which of the following are included in the purpose of documentation?
• Which statement best describes the roles and functions of the healthcare team?
• Which term describes the professional care of patients, especially in a hospital?
• In Focus Charting, which component records the nurse's assessment and clinical judgments?
• The phrase 'Timely and accurate documentation' best corresponds to which concept?
• An ongoing effort to improve products, services, or processes.
• Which action best prevents medication errors?
• Which outcome indicates successful preoperative patient assistance?
• In SBAR, which component requests a course of action or recommendation?
• Which description emphasizes the professional path that includes advanced degrees and specialization in nursing?
• Which concept focuses on maintaining accurate records for legal and clinical purposes?
• What is the outcome of effective patient assistance before surgery?
• Which category involves Introduces Self, Patient Identification, Allergy Check, VS from Monitor, What Brought you to the Hospital? Focus Assessment on Chief Complaint, Re-Assess after Medication/Treatment.
• What is the primary purpose of a thorough hand-off report between care providers?
• Which concept concerns strategies for organizing a hospital shift?
• In delegation, the phrase 'Under the right circumstances' refers to which principle?
• Which term describes an organization-wide approach to continuous improvement focusing on customer satisfaction?
• Which item addresses ensuring appropriate supervision for students and preventing role confusion?
• A process by which entities review the quality of all factors involved in production.
• Which statement best matches 'Follow facility policies and procedures'?
• Which devices are used to prevent venous thromboembolism in immobile patients?
• Which role provides both primary and specialty care and has advanced training?
• Which measure is used to assess patient experience with healthcare providers and systems?
• What is a critical consideration when recording patient assistance before surgery?
• Which factors affect the cost of health care?
• Which concept is described by 'Clear and concise communication with healthcare team'?
• Which role would be best described as conducting scholarly inquiry to advance nursing science and publish findings?
• Which administrative action supports quality and safety in preoperative care?
• According to the American Nurses Association, which statement best reflects the definition of nursing?
• Who is identified as the nurse who established the Red Cross in the United States?
• A nurse has volunteered to give influenza vaccines at a local clinic. This demonstrates which level of care demonstrated by nurse?
• In electronic documentation, what concerns confidentiality?
• What does the abbreviation EHR stand for?
• In SOAP charting, which section documents the plan of care?
• Which items are included in Additional Types of Entries?
• Which category includes Gather Supplies, Perform Procedure with Patient Explanation including Safety, Rails, Call Light, TEDS, SCDs, Specimen Collection, Guaiac, Restraints, Head of Bed, Oxygen, TCDB, IS, Enteral, Catheterization, Dressing Change, Start IV, Draw Blood, Administer Blood, etc.
• The statement 'DO NOT mix your role as a student nurse with any other health care role you may practice in' refers to which concept?
• Which factor is explicitly cited as contributing to rising healthcare costs?
• In PIE format, which component includes the data collected about the patient (subjective and objective)?
• Which nursing care delivery model is described as efficient and cost-effective but often involves large assignments, fragmented care, and little individualized attention?
• Which of the following are listed as purposes of nursing documentation?
• Quality individualized care but can be expensive.
• Which formats are included in Special Population Documentation?
• Which are types of entries in nursing documentation?
• Administering the ordered antibiotic to the patient before surgery is an example of which action?
• Which approach emphasizes using flow sheets, prioritizing care using Maslow's Hierarchy and ABCs, organizing patient care, good communication with the healthcare team, and delegating tasks as needed?
• What is the definition of delegation in nursing practice?
• Which documentation tools are commonly used with the SOAP format?
• Which characteristics define good documentation?
• Some agencies require two nurses sign TOs/VOs. Who must sign?
• In PIE format, which element records the nursing interventions?
• The principle 'With the right directions and communication' corresponds to which concept?
• A systematic approach to making changes that lead to better patient outcomes.
• Which action describes the health care provider cosigning orders within the required time frame?
• Which nurse explores the ethical and theoretical aspects of nursing practice?
• Which setting is most likely to be an inpatient, acute care environment?
• Which of the following best describes the purpose of preoperative patient assistance documentation?
• What is the most appropriate action to support dignity and safety when preparing a patient for surgery?
• When documenting a telephone or verbal order, which items should be included?
• Which set of measures is used to assess patient experiences in hospitals, including aspects like communication with nurses and doctors, and discharge information?
• In medication administration, which step involves barcode scanning to verify patient identity and medication?
• Which term is defined as preventing errors or defects in products and services?
• Why is The Joint Commission (TJC) important to a healthcare organization?
• Which concept guides staffing decisions by evaluating patient care needs over a 24-hour period?
• Which term describes an organized framework of care across settings to ensure continuity of care?
• Which term describes the educational pathways that include Diploma, Associate, Baccalaureate, Graduate degree entry program, Continuing education, and In-service education?