NURS 121L-A: Medical-Surgical Nursing Practicum - Clinical
Documentation & Reporting Exam 2026 |WCU
1. When providing a hand-off report using the ISBAR tool, which information
belongs in the ‘Background’ section?
A. The admitting diagnosis, medical history, and current allergies.
B. The patient’s current vital signs and most recent pain level.
C. A specific request for a change in the patient’s medication dose.
D. The nurse’s name, the unit, and the patient’s name.
Answer: A
Rationale: Background (B) includes the context leading up to the current situation, such as
medical history, admitting diagnosis, and relevant clinical history.
2. A nurse discovers a medication error and immediately notifies the provider.
When documenting the incident, which action is most appropriate?
A. Include a note in the patient’s medical record stating an incident report was filed.
B. Omit the error from the medical record to prevent legal discovery during a lawsuit.
C. Wait until the nurse manager reviews the error before charting any details.
D. Document the facts of the error, the provider notification, and patient response in the medical record.
Answer: D
Rationale: Clinical documentation should include factual accounts of what happened, who
was notified, and patient outcomes. The incident report itself is an internal document and
should not be mentioned in the medical record.
,3. Which entry is the best example of objective documentation?
A. Patient appeared to be in a great deal of pain and was very grumpy.
B. Patient was non-compliant with the respiratory therapist’s instructions.
C. Patient seems to be feeling better after the morning walk.
D. Patient’s surgical dressing is dry and intact; no drainage noted.
Answer: D
Rationale: Objective documentation describes observable, measurable facts without bias
or interpretation. Dressing status is a factual observation.
4. A nurse is correcting an error in a handwritten clinical entry. What is the
legally accepted method for this?
A. Use white-out to completely cover the error and write over it.
B. Black out the error with a felt-tip marker so it cannot be read.
C. Erasing the error with a high-quality eraser and rewriting the data.
D. Draw a single line through the entry, write ‘error,’ and initial it.
Answer: D
Rationale: A single line maintains the legibility of the original entry, which is a legal
requirement to show transparency in the medical record.
5. Under HIPAA, when is it permissible for a nurse to share patient information
with a family member?
A. Whenever the family member asks for a status update on the phone.
B. When the patient is sleeping and the family member looks worried.
C. If the family member is the one who brought the patient to the hospital.
D. Only if the patient has provided explicit verbal or written consent.
Answer: D
Rationale: Patient privacy is protected by HIPAA, and information can only be shared with
those for whom the patient has granted permission.
, 6. In ‘Charting by Exception’ (CBE), what is the primary requirement for a
nurse’s documentation?
A. Documenting every routine care activity provided during the shift.
B. Using a specific color of ink for different types of nursing interventions.
C. Writing a lengthy narrative note at the end of every four hours.
D. Only documenting findings that fall outside of the established standard of care.
Answer: D
Rationale: CBE assumes that all standards are met unless otherwise documented;
therefore, only ‘exceptions’ or significant findings are charted.
7. Which abbreviation is included on The Joint Commission’s ‘Official Do Not
Use’ list?
A. mg
B. U (unit)
C. NPO
D. PRN
Answer: B
Rationale: The abbreviation ‘U’ can be mistaken for the number 0, 4, or ‘cc’. The word ‘unit’
should always be written out.
8. What is the most critical action a nurse must take after receiving a telephone
order from a provider?
A. Immediately transcribe the order into the MAR.
B. Ask another nurse to listen to the provider on speakerphone.
C. Read the order back to the provider to confirm accuracy.
D. Document the order and sign it as if the provider wrote it.
Answer: C
Rationale: The ‘read-back’ process is a safety standard to ensure that the nurse correctly
heard and understood the verbal or telephone order.
Documentation & Reporting Exam 2026 |WCU
1. When providing a hand-off report using the ISBAR tool, which information
belongs in the ‘Background’ section?
A. The admitting diagnosis, medical history, and current allergies.
B. The patient’s current vital signs and most recent pain level.
C. A specific request for a change in the patient’s medication dose.
D. The nurse’s name, the unit, and the patient’s name.
Answer: A
Rationale: Background (B) includes the context leading up to the current situation, such as
medical history, admitting diagnosis, and relevant clinical history.
2. A nurse discovers a medication error and immediately notifies the provider.
When documenting the incident, which action is most appropriate?
A. Include a note in the patient’s medical record stating an incident report was filed.
B. Omit the error from the medical record to prevent legal discovery during a lawsuit.
C. Wait until the nurse manager reviews the error before charting any details.
D. Document the facts of the error, the provider notification, and patient response in the medical record.
Answer: D
Rationale: Clinical documentation should include factual accounts of what happened, who
was notified, and patient outcomes. The incident report itself is an internal document and
should not be mentioned in the medical record.
,3. Which entry is the best example of objective documentation?
A. Patient appeared to be in a great deal of pain and was very grumpy.
B. Patient was non-compliant with the respiratory therapist’s instructions.
C. Patient seems to be feeling better after the morning walk.
D. Patient’s surgical dressing is dry and intact; no drainage noted.
Answer: D
Rationale: Objective documentation describes observable, measurable facts without bias
or interpretation. Dressing status is a factual observation.
4. A nurse is correcting an error in a handwritten clinical entry. What is the
legally accepted method for this?
A. Use white-out to completely cover the error and write over it.
B. Black out the error with a felt-tip marker so it cannot be read.
C. Erasing the error with a high-quality eraser and rewriting the data.
D. Draw a single line through the entry, write ‘error,’ and initial it.
Answer: D
Rationale: A single line maintains the legibility of the original entry, which is a legal
requirement to show transparency in the medical record.
5. Under HIPAA, when is it permissible for a nurse to share patient information
with a family member?
A. Whenever the family member asks for a status update on the phone.
B. When the patient is sleeping and the family member looks worried.
C. If the family member is the one who brought the patient to the hospital.
D. Only if the patient has provided explicit verbal or written consent.
Answer: D
Rationale: Patient privacy is protected by HIPAA, and information can only be shared with
those for whom the patient has granted permission.
, 6. In ‘Charting by Exception’ (CBE), what is the primary requirement for a
nurse’s documentation?
A. Documenting every routine care activity provided during the shift.
B. Using a specific color of ink for different types of nursing interventions.
C. Writing a lengthy narrative note at the end of every four hours.
D. Only documenting findings that fall outside of the established standard of care.
Answer: D
Rationale: CBE assumes that all standards are met unless otherwise documented;
therefore, only ‘exceptions’ or significant findings are charted.
7. Which abbreviation is included on The Joint Commission’s ‘Official Do Not
Use’ list?
A. mg
B. U (unit)
C. NPO
D. PRN
Answer: B
Rationale: The abbreviation ‘U’ can be mistaken for the number 0, 4, or ‘cc’. The word ‘unit’
should always be written out.
8. What is the most critical action a nurse must take after receiving a telephone
order from a provider?
A. Immediately transcribe the order into the MAR.
B. Ask another nurse to listen to the provider on speakerphone.
C. Read the order back to the provider to confirm accuracy.
D. Document the order and sign it as if the provider wrote it.
Answer: C
Rationale: The ‘read-back’ process is a safety standard to ensure that the nurse correctly
heard and understood the verbal or telephone order.
