1) Below are the essential elements for nursing documentation EXCEPT: a) Clear b) Accurate c) Accesible d) Copy and paste 2) The following are the importance of documentation, EXCEPT: a) Continuity of care b) Evidence of care c) To record only about doctor's ward round and orders d) Source of information for other healthcare providers 3) Which of the following is NOT the component of good quality documentation? a) Factual b) Organised c) Confusing d) Current / Timely 4) If an error occurs in paper documentation, you should a) Correct it with correction tape b) Scribble it out c) Draw a single line through the record, indicate 'error' and initial d) Inform superior 5) Correct sequence of nursing process is a) Interview → Assessment → Planning → Intervention → Evaluation b) Interview → Diagnosis → Planning → Intervention → Evaluation c) Assessment → Diagnosis → Planning → Intervention → Evaluation d) Assessment → Interview → Planning → Intervention → Evaluation 6) All statements are true regarding NCP EXCEPT: a) NCP is a product of nursing process b) NCP is individualized and can be modified c) Can change from day to day d) Focuses on curing the disease 7) Which of the following is NOT the components of NCP?  a) Nursing Diagnosis with supporting data b) Expected Outcome / Goals c) Assessment d) Evaluation 8) A nurse is performing an initial assessment for a patient. Which of the following would be considered subjective information received during the assessment? a) The client rates pain at a level of 6 on the numeric rating scale b) The client has rashes on the face and trunk c) The patient weighs 60kg d) The patient's blood pressure increases when the doctor enters the room 9) When planning nursing care for a patient, which example best describes an outcome that is measurable? a) The patient will have control of his back pain b) The patient will be able to ambulate to the end of the corridor within 2 days c) The patient will verbalize anxiety reduced and feel better d) Pain score less than 2 10) The nurse identifies a patient's responses to actual or potential health problems during which step of the nursing process? a) Assessing b) Diagnosing c) Planning d) Evaluating 11) A patient who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this patient? a) Acute pain related to surgery b) Deficient fluid volume related to blood and fluid loss from surgery c) Impaired physical mobility related to general anesthesia d) Risk for aspiration related to general anesthesia 12) While the nurse is providing a patient personal hygiene, she observes that his skin is excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate nursing diagnosis would be: a) Potential for impaired skin integrity related to altered gland function b) Potential for impaired skin integrity related to dehydration c) Impaired skin integrity related to dehydration d) Impaired skin integrity related to altered circulation 13) Objective data is observable and measuarable. a) True b) False 14) Which of the following is excluded during evaluation? a) Determination of goal achievement b) Collection of data c) Revising the NCP d) Performing nursing orders 15) Which if the following statement is TRUE about nursing diagnosis? a) Stays the same as long as the disease is present. b) Stays the same throughout hospitalization. c) All patient should have only 2 nursing diagnosis. d) It is within the scope of nursing practice. 16) Which step in nursing process involves collecting subjective and objective data about the patient? a) Assessment b) Planning c) Intervention d) Nursing diagnosis 17) Nursing goals should be SMART. What dost the 'A' stands for? a) Attainable b) Applicable c) Acceptable d) Adjustable 18) Which of the following is the most appropriate evaluation statement for nursing goal: 'No episode of fall' a) Patient on AI SmartPeep monitoring b) Both side rails up, call bell within reach. c) No fall occurred. d) Both side rails up, call bell within reach, ICR done. Fall precaution applied. 19) Which if the following is an example of subjective data? a) Vital signs b) Lab results c) Physical examination findings d) Patient reported pain level 20) Which of the following issues should be given the highest priority? a) Acute pain b) Impaired in mobility c) Self-care deficit d) Impaired gas exchange

Nursing Documentation & NCP

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