A nurse is using the SOAP documentation format to chart on their patient in a systematic and organized way. When using SOAP, what sections would be present in the charting? Select all that apply.

Assessment.

Subjective.

Plan.

Problems.

Answer and Explanation

Correct Answer : A,B,C

SOAP is an acronym for subjective, objective, assessment, and plan, which are the four sections that should be present in the charting. The subjective section includes the client's report of symptoms or how they feel. The objective section includes the nurse's observations of the patient, such as vital signs and physical examination findings. The assessment section includes the nurse's analysis of the subjective and objective data to identify health problems, while the plan section includes the nurse's plan of care for the patient, including interventions and goals.

The problem section is not typically included in SOAP documentation but may be included in other formats such as SOAPIE or DAR.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Answer and Explanation

The correct answer is choice C, Read back the order to the physician.

After obtaining the physician's order over the phone, the nurse should read back the order to the physician to confirm accuracy and prevent medication errors.

This process ensures that the order is correctly transcribed and the right medication, dose, and route are given to the patient. Calling the pharmacy to check medication availability is not the nurse's responsibility, and initiating the prescription and administering the medication is inappropriate without confirming the order with the physician. Drawing up the medication into an appropriately labeled syringe before confirming the order with the physician is also inappropriate and can lead to medication errors. Therefore, reading back the order to the physician is the most appropriate action for the nurse to take.

A. Documenting an assessment that was not performed B. The nurse documents that the family has asked to speak to the doctor C. The nurse fails to document the doctor's verbal order for a new medication D. The nurse left their badge at home and cannot sign into the EHR E. The nurse documents blood labs were sent before the blood draw was performed

Correct Answer is ["A","E"]

Explanation

Correct answers are:

A. Documenting an assessment that was not performed

E. The nurse documents blood labs were sent before the blood draw was performed

Falsification of health records refers to deliberately misrepresenting, fabricating, or altering documentation, which could lead to severe consequences for patients and healthcare providers. In option A, documenting an assessment that was not performed is falsification of health records because it misrepresents the care provided to the patient. Similarly, in option E, documenting that blood labs were sent before the blood draw was performed is a falsification of health records because it is not an accurate representation of the actual order of events.

Options B, C, and D do not involve falsification of health records, but they may be considered documentation errors or violations of organizational policies.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is using the SOAP documentation format to chart on their patient in a systematic and organized way. When using SOAP, what sections would be present in the charting? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which of the following would be falsification of health records? Select all that apply.

Correct Answer is ["A","E"]

Explanation

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

When conducting a physical assessment of the extremities, which of the following assessments would be the most correct?

Which statement by a nurse would be the most therapeutic response to a patient who cannot decide if they want to receive recommended chemotherapy treatment?

Which technique should the nurse use to assess the pupillary reaction on a client?

Upon responding to the client's call bell, the nurse discovers the client's abdominal wound has been eviscerated. Initial nursing management includes calling the healthcare provider and which other initial action?

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem. Which assessment cues would support constipation? Select all that apply.

A patient has an order for Normal Saline 1000 mL to infuse over 3 hours. The medication will be infused with an IV pump. How many mL/h should the IV pump be programmed for?