Chapter 20 Practice Questions
1. A hospital utilizes the SOAP method of charting. Within this model, which of the
nurse's statements would appear at the beginning of a charting entry?
A. "Client is reporting abdominal pain is rated at 8/10."
B. "Client is guarding the abdomen and occasionally moaning."
C. "Client has a history of recent abdominal pain."
D. "2 mg hydromorphone hydrochloride PO was administered with good effect."
2. Which data entry follows the recommended guidelines for documenting data?
A. "Client is overwhelmed by the diagnosis of pancreatic cancer."
B. "Client's kidneys are producing sufficient amount of measured urine."
C. "Following oxygen administration, vital signs returned to baseline."
D. "Client complained about the quality of the nursing care provided on previous
shift."
3. A student has reviewed a client's chart before beginning assigned care. Which
action violates client confidentiality?
A. writing the client's name on the student care plan
B. providing the instructor with plans for care
C. discussing the medications with a unit nurse
D. providing information to the physician about laboratory data
4. Which method of documenting client data is least likely to hold up in court if a
case of negligence is brought against a nurse?
A. problem-oriented medical record
B. charting by exception
C. PIE charting system
D. FOCUS charting
5. Which part of the client's record is commonly used to document specific client
variables, such as vital signs?
A. progress notes
B. nursing notes
C. critical paths
D. flow sheets
6. The client is admitted to the hospital for a surgical procedure and has gone
through several areas of the hospital in one day. Nurses have been providing care
and charting about the condition of the client throughout the day. When would the
nurse chart a progress note about the client? Select all that apply.
A. For any nurse–client interaction
B. When admitting the client to the surgical admissions unit
C. When receiving the client postoperatively on the surgical floor
D. Prior to assisting the client up to the bathroom to void
E. When the surgical procedure is performed
7. The nurse notes that the blood glucose level of a client has increased and is
planning to notify the health care provider by telephone. Which technique would be
