HESI EXAM: Documentation & Legal
Aspects Of Nursing (2026 Update)||
Questions And Answers With
Rationales/Graded A+/2026
Update/100% Correct /Instant
Download
SECTION A: Principles of Documentation (25 questions)
1. A nurse is charting on a patient with pressure injury. Which entry follows
the "PIE" (Problem-Intervention-Evaluation) method?
A. “0800: Dressing dry and intact. Will continue to monitor.”
B. “0800: Risk for impaired skin integrity. Applied foam dressing. 1200: Mild
erythema noted but skin intact.”
C. “0800: Patient turned q2h. No complaints.”
D. “0800: Wound vac at –125 mmHg. Output 50 mL.”
Rationale: PIE = Problem (risk for impaired skin), Intervention (foam dressing),
Evaluation (erythema). Options A and C lack the problem statement; D is
intervention only.
2. Which abbreviation is still permitted by the Joint Commission’s “Do Not
Use” list in 2026?
A. U (for unit)
B. QD (daily)
C. mcg
D. MS
Rationale: “mcg” is acceptable for microgram. “U” (confused with 0, 4), “QD”
(confused with QID), and “MS” (confused with magnesium sulfate) are banned.
,3. A nurse documents: “Patient appears anxious.” This is an example of:
A. Objective data
B. Subjective data interpreted as objective
C. Legal safeguard
D. Incident report content
Rationale: “Appears anxious” is subjective interpretation, not measurable.
Objective would be “heart rate 110, patient states ‘I feel scared.’”
4. According to HIPAA, which of the following is a permissible disclosure
without patient consent?
A. Patient’s diagnosis to employer
B. Lab results to patient’s neighbor
C. Report of a gunshot wound to law enforcement
D. Medication list to insurance company for billing
Rationale: Permitted disclosures include mandatory reporting (abuse, gunshot
wounds, certain communicable diseases). Billing requires consent or TPO
(treatment, payment, operations) but employer/neighbor are not allowed.
5-7. Select all that apply (SATA): Proper documentation should include:
A. Use of black ink (or approved electronic signature)
B. Correction with single line, initial, date, and “error”
C. Late entries labeled “late entry” with current time and original time
D. Use of white-out to correct mistakes
E. Signature with credentials after each entry
Rationale: White-out is prohibited. All others are current standards (2026 EHR
may use strike-through with audit trail).
8. A nurse realizes she documented an incorrect blood pressure (140/90 instead
of 120/80). What is the correct correction in an electronic health record
(EHR)?
A. Delete the entry completely.
, B. Overtype the correct number.
C. Enter an addendum stating correction, with original entry remaining
visible and struck through.
D. Leave it and document a new BP as a late entry.
Rationale: EHRs require an audit trail; corrections must preserve original entry
per legal standards.
9. The nurse is charting using DAR (Data, Action, Response). Which is
correctly formatted?
A. D: 0900—lung sounds clear. A: breathing treatment. R: states better.
B. D: 0900—O2 sat 88% on RA. A: applied NC at 2L. R: 1000 O2 sat 94%.
C. D: patient tired. A: rest period. R: slept.
D. D: pain. A: morphine. R: relief.
Rationale: B has measurable data, specific action, and timed response. Others are
vague.
10. A patient refuses a scheduled insulin injection. The nurse should:
A. Document “patient noncompliant”
B. Document “patient refused insulin at 0800; education provided; MD
notified”
C. Not document refusal to avoid legal liability
D. Administer it anyway per sliding scale
Rationale: Refusal must be documented factually, including notification of
provider.
11. Which of the following is NOT a legal function of the medical record?
A. Communication among providers
B. Reimbursement evidence
C. Personal notes for nurse’s memory
D. Legal defense in malpractice
Rationale: Personal notes (brain sheets) are not part of the legal medical record
unless scanned in.
Aspects Of Nursing (2026 Update)||
Questions And Answers With
Rationales/Graded A+/2026
Update/100% Correct /Instant
Download
SECTION A: Principles of Documentation (25 questions)
1. A nurse is charting on a patient with pressure injury. Which entry follows
the "PIE" (Problem-Intervention-Evaluation) method?
A. “0800: Dressing dry and intact. Will continue to monitor.”
B. “0800: Risk for impaired skin integrity. Applied foam dressing. 1200: Mild
erythema noted but skin intact.”
C. “0800: Patient turned q2h. No complaints.”
D. “0800: Wound vac at –125 mmHg. Output 50 mL.”
Rationale: PIE = Problem (risk for impaired skin), Intervention (foam dressing),
Evaluation (erythema). Options A and C lack the problem statement; D is
intervention only.
2. Which abbreviation is still permitted by the Joint Commission’s “Do Not
Use” list in 2026?
A. U (for unit)
B. QD (daily)
C. mcg
D. MS
Rationale: “mcg” is acceptable for microgram. “U” (confused with 0, 4), “QD”
(confused with QID), and “MS” (confused with magnesium sulfate) are banned.
,3. A nurse documents: “Patient appears anxious.” This is an example of:
A. Objective data
B. Subjective data interpreted as objective
C. Legal safeguard
D. Incident report content
Rationale: “Appears anxious” is subjective interpretation, not measurable.
Objective would be “heart rate 110, patient states ‘I feel scared.’”
4. According to HIPAA, which of the following is a permissible disclosure
without patient consent?
A. Patient’s diagnosis to employer
B. Lab results to patient’s neighbor
C. Report of a gunshot wound to law enforcement
D. Medication list to insurance company for billing
Rationale: Permitted disclosures include mandatory reporting (abuse, gunshot
wounds, certain communicable diseases). Billing requires consent or TPO
(treatment, payment, operations) but employer/neighbor are not allowed.
5-7. Select all that apply (SATA): Proper documentation should include:
A. Use of black ink (or approved electronic signature)
B. Correction with single line, initial, date, and “error”
C. Late entries labeled “late entry” with current time and original time
D. Use of white-out to correct mistakes
E. Signature with credentials after each entry
Rationale: White-out is prohibited. All others are current standards (2026 EHR
may use strike-through with audit trail).
8. A nurse realizes she documented an incorrect blood pressure (140/90 instead
of 120/80). What is the correct correction in an electronic health record
(EHR)?
A. Delete the entry completely.
, B. Overtype the correct number.
C. Enter an addendum stating correction, with original entry remaining
visible and struck through.
D. Leave it and document a new BP as a late entry.
Rationale: EHRs require an audit trail; corrections must preserve original entry
per legal standards.
9. The nurse is charting using DAR (Data, Action, Response). Which is
correctly formatted?
A. D: 0900—lung sounds clear. A: breathing treatment. R: states better.
B. D: 0900—O2 sat 88% on RA. A: applied NC at 2L. R: 1000 O2 sat 94%.
C. D: patient tired. A: rest period. R: slept.
D. D: pain. A: morphine. R: relief.
Rationale: B has measurable data, specific action, and timed response. Others are
vague.
10. A patient refuses a scheduled insulin injection. The nurse should:
A. Document “patient noncompliant”
B. Document “patient refused insulin at 0800; education provided; MD
notified”
C. Not document refusal to avoid legal liability
D. Administer it anyway per sliding scale
Rationale: Refusal must be documented factually, including notification of
provider.
11. Which of the following is NOT a legal function of the medical record?
A. Communication among providers
B. Reimbursement evidence
C. Personal notes for nurse’s memory
D. Legal defense in malpractice
Rationale: Personal notes (brain sheets) are not part of the legal medical record
unless scanned in.
