2 M A X E • S L AT N E M A D N U F
★ ★
Nursing Fundamentals Assessment
N Comprehensive Examination — Exam 2
EST. 2026
E XC E L L E N C E I N N U RS I N G E D U C AT I O N
Fundamentals of Nursing — Exam 2
D O C U M E N TAT I O N , I N F E C T I O N CO N T R O L , U R I N A R Y E L I M I N AT I O N & W O U N D C A R E
INSTITUTION Nursing Fundamentals Assessment COURSE CODE Fundamentals of Nursing — Exam 2
PROGRAM Practical Nursing (PN) / Associate Degree ACADEMIC YEAR
in Nursing (ADN)
EXAM TITLE Fundamentals of Nursing Exam 2 TOTAL QUESTIONS 50 Questions
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions are indicated — choose every correct option.
▸ Questions cover documentation, infection control, urinary elimination, and wound care.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All content reflects current evidence-based nursing practice and standards.
SECTION I — FUNDAMENTALS OF NURSING COMPREHENSIVE Questions 1 –
EXAMINATION 50
1. What is the primary purpose of the patient record?
A. To serve as a personal diary for the nurse.
B. Communication between disciplines, legal documentation, financial billing, education, research, and auditing.
C. To provide reading material for patients.
D. To serve as the only document needed for nursing handoff.
CORRECT ANSWER B — Communication between disciplines, legal documentation, financial billing, education, research,
and auditing.
RATIONALE The patient record is the only permanent legal document detailing the nurse's interactions with the patient. It
serves multiple essential purposes: communication among healthcare team members, legal documentation
(admissible in court), financial reimbursement, education of healthcare students, clinical research, and
auditing/monitoring quality of care. It is not a personal diary, reading material for patients, or a substitute for
verbal handoff communication.
,2. Which of the following is a prohibited abbreviation per JCAHO safety goals?
A. "U" for units.
B. "mL" for milliliters.
C. "mg" for milligrams.
D. "PO" for by mouth.
CORRECT ANSWER A — "U" for units.
RATIONALE JCAHO's "Do Not Use" list includes: "U" (can be mistaken for 0, 4, or cc — write "unit"), "IU" (write
"international unit"), "Q.D." and "Q.O.D." (write "daily" or "every other day"), trailing zeros (1.0 can be
mistaken for 10 — never write a zero after a decimal), lack of leading zero (.5 can be mistaken for 5 — always
write 0.5), "MS" (write "morphine sulfate" or "magnesium sulfate"), and "MSO₄" and "MgSO₄" (confused with
each other). These are national patient safety requirements.
3. What does the legal principle "If it was not documented, it was not done" mean?
A. Nurses should document everything they plan to do before doing it.
B. In a court of law, any care not documented in the patient record is assumed to have not been performed.
C. Verbal communication can replace documentation.
D. Only medications need to be documented.
CORRECT ANSWER B — In a court of law, any care not documented in the patient record is assumed to have not been
performed.
RATIONALE The medical record is a legal document. If care, assessment, teaching, or an intervention is not documented,
there is no proof it occurred. In malpractice litigation, the standard is: "If it wasn't documented, it wasn't
done." Nurses should NEVER chart prior to the event — documentation must be contemporaneous (at the
time of or immediately after care). Verbal communication supplements but does not replace written
documentation. All aspects of care — assessments, interventions, medications, teaching, and patient
responses — must be documented.
4. The nurse makes an error while documenting in a handwritten note. What is the correct action?
A. Use correction fluid to cover the error completely.
B. Erase the error thoroughly.
C. Draw a single line through the error, write "error" above it, initial, and continue.
D. Cross out the entire page and start over.
CORRECT ANSWER C — Draw a single line through the error, write "error" above it, initial, and continue.
RATIONALE Legal documentation correction: draw ONE line through the error so the original text remains legible, write
"error" above it, add the date and your initials, and then write the correct information. Correction fluid,
erasing, or obliterating text suggests fraudulent alteration. The original entry must remain readable for legal
purposes. In electronic records, follow the facility's procedure for making corrections — most EHRs have an
"addendum" or "correction" function that preserves the original entry with a timestamp.
, 5. What does VORB stand for?
A. Visual Order Review Board.
B. Verbal Order Read Back.
C. Vital Observation Record Book.
D. Verified Online Reporting Base.
CORRECT ANSWER B — Verbal Order Read Back.
RATIONALE VORB (Verbal Order Read Back) is a patient safety protocol for telephone and verbal orders. The nurse writes
the complete order as received, reads it back to the prescriber verbatim, and receives confirmation that it was
correctly understood. This prevents transcription errors. The order must be signed by the prescriber within
the facility's specified timeframe (usually 24 hours). Having a second nurse listen when possible provides an
additional safety check. This is distinct from TORB (Telephone Order Read Back) — same principle.
6. What is an incident (variance) report?
A. A report filed in the patient's medical record documenting a medication error.
B. A report of any event not consistent with routine operations that resulted in or could have resulted in harm to a
patient, employee, or visitor.
C. A daily summary of the patient's condition.
D. A report card evaluating the nurse's performance.
CORRECT ANSWER B — A report of any event not consistent with routine operations that resulted in or could have
resulted in harm to a patient, employee, or visitor.
RATIONALE An incident (variance/occurrence) report documents any unexpected event — medication errors, falls,
needlestick injuries, equipment malfunction, or visitor accidents. It is an INTERNAL quality improvement tool
and is NEVER placed in the patient's medical record. The medical record documents the FACTS of the event
and the patient's response — it should NEVER reference that an incident report was filed. Incident reports are
used for root cause analysis, trend tracking, and system improvement — not for disciplinary purposes.
7. What is the most effective intervention to break the chain of infection?
A. Wearing sterile gloves for all patient contact.
B. Hand hygiene.
C. Placing all patients in private rooms.
D. Administering prophylactic antibiotics.
CORRECT ANSWER B — Hand hygiene.
RATIONALE Hand hygiene is the single most effective measure to prevent transmission of infectious agents and break the
chain of infection at any link. Alcohol-based hand rubs are preferred for routine use (fast, effective against
most organisms). Soap and water is required when hands are visibly soiled, after restroom use, and for C.
difficile (alcohol does not kill spores). Proper technique requires 15–20 seconds of friction covering all
surfaces. The chain of infection includes: Infectious Agent → Reservoir → Portal of Exit → Mode of
Transmission → Portal of Entry → Susceptible Host.
★ ★
Nursing Fundamentals Assessment
N Comprehensive Examination — Exam 2
EST. 2026
E XC E L L E N C E I N N U RS I N G E D U C AT I O N
Fundamentals of Nursing — Exam 2
D O C U M E N TAT I O N , I N F E C T I O N CO N T R O L , U R I N A R Y E L I M I N AT I O N & W O U N D C A R E
INSTITUTION Nursing Fundamentals Assessment COURSE CODE Fundamentals of Nursing — Exam 2
PROGRAM Practical Nursing (PN) / Associate Degree ACADEMIC YEAR
in Nursing (ADN)
EXAM TITLE Fundamentals of Nursing Exam 2 TOTAL QUESTIONS 50 Questions
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions are indicated — choose every correct option.
▸ Questions cover documentation, infection control, urinary elimination, and wound care.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All content reflects current evidence-based nursing practice and standards.
SECTION I — FUNDAMENTALS OF NURSING COMPREHENSIVE Questions 1 –
EXAMINATION 50
1. What is the primary purpose of the patient record?
A. To serve as a personal diary for the nurse.
B. Communication between disciplines, legal documentation, financial billing, education, research, and auditing.
C. To provide reading material for patients.
D. To serve as the only document needed for nursing handoff.
CORRECT ANSWER B — Communication between disciplines, legal documentation, financial billing, education, research,
and auditing.
RATIONALE The patient record is the only permanent legal document detailing the nurse's interactions with the patient. It
serves multiple essential purposes: communication among healthcare team members, legal documentation
(admissible in court), financial reimbursement, education of healthcare students, clinical research, and
auditing/monitoring quality of care. It is not a personal diary, reading material for patients, or a substitute for
verbal handoff communication.
,2. Which of the following is a prohibited abbreviation per JCAHO safety goals?
A. "U" for units.
B. "mL" for milliliters.
C. "mg" for milligrams.
D. "PO" for by mouth.
CORRECT ANSWER A — "U" for units.
RATIONALE JCAHO's "Do Not Use" list includes: "U" (can be mistaken for 0, 4, or cc — write "unit"), "IU" (write
"international unit"), "Q.D." and "Q.O.D." (write "daily" or "every other day"), trailing zeros (1.0 can be
mistaken for 10 — never write a zero after a decimal), lack of leading zero (.5 can be mistaken for 5 — always
write 0.5), "MS" (write "morphine sulfate" or "magnesium sulfate"), and "MSO₄" and "MgSO₄" (confused with
each other). These are national patient safety requirements.
3. What does the legal principle "If it was not documented, it was not done" mean?
A. Nurses should document everything they plan to do before doing it.
B. In a court of law, any care not documented in the patient record is assumed to have not been performed.
C. Verbal communication can replace documentation.
D. Only medications need to be documented.
CORRECT ANSWER B — In a court of law, any care not documented in the patient record is assumed to have not been
performed.
RATIONALE The medical record is a legal document. If care, assessment, teaching, or an intervention is not documented,
there is no proof it occurred. In malpractice litigation, the standard is: "If it wasn't documented, it wasn't
done." Nurses should NEVER chart prior to the event — documentation must be contemporaneous (at the
time of or immediately after care). Verbal communication supplements but does not replace written
documentation. All aspects of care — assessments, interventions, medications, teaching, and patient
responses — must be documented.
4. The nurse makes an error while documenting in a handwritten note. What is the correct action?
A. Use correction fluid to cover the error completely.
B. Erase the error thoroughly.
C. Draw a single line through the error, write "error" above it, initial, and continue.
D. Cross out the entire page and start over.
CORRECT ANSWER C — Draw a single line through the error, write "error" above it, initial, and continue.
RATIONALE Legal documentation correction: draw ONE line through the error so the original text remains legible, write
"error" above it, add the date and your initials, and then write the correct information. Correction fluid,
erasing, or obliterating text suggests fraudulent alteration. The original entry must remain readable for legal
purposes. In electronic records, follow the facility's procedure for making corrections — most EHRs have an
"addendum" or "correction" function that preserves the original entry with a timestamp.
, 5. What does VORB stand for?
A. Visual Order Review Board.
B. Verbal Order Read Back.
C. Vital Observation Record Book.
D. Verified Online Reporting Base.
CORRECT ANSWER B — Verbal Order Read Back.
RATIONALE VORB (Verbal Order Read Back) is a patient safety protocol for telephone and verbal orders. The nurse writes
the complete order as received, reads it back to the prescriber verbatim, and receives confirmation that it was
correctly understood. This prevents transcription errors. The order must be signed by the prescriber within
the facility's specified timeframe (usually 24 hours). Having a second nurse listen when possible provides an
additional safety check. This is distinct from TORB (Telephone Order Read Back) — same principle.
6. What is an incident (variance) report?
A. A report filed in the patient's medical record documenting a medication error.
B. A report of any event not consistent with routine operations that resulted in or could have resulted in harm to a
patient, employee, or visitor.
C. A daily summary of the patient's condition.
D. A report card evaluating the nurse's performance.
CORRECT ANSWER B — A report of any event not consistent with routine operations that resulted in or could have
resulted in harm to a patient, employee, or visitor.
RATIONALE An incident (variance/occurrence) report documents any unexpected event — medication errors, falls,
needlestick injuries, equipment malfunction, or visitor accidents. It is an INTERNAL quality improvement tool
and is NEVER placed in the patient's medical record. The medical record documents the FACTS of the event
and the patient's response — it should NEVER reference that an incident report was filed. Incident reports are
used for root cause analysis, trend tracking, and system improvement — not for disciplinary purposes.
7. What is the most effective intervention to break the chain of infection?
A. Wearing sterile gloves for all patient contact.
B. Hand hygiene.
C. Placing all patients in private rooms.
D. Administering prophylactic antibiotics.
CORRECT ANSWER B — Hand hygiene.
RATIONALE Hand hygiene is the single most effective measure to prevent transmission of infectious agents and break the
chain of infection at any link. Alcohol-based hand rubs are preferred for routine use (fast, effective against
most organisms). Soap and water is required when hands are visibly soiled, after restroom use, and for C.
difficile (alcohol does not kill spores). Proper technique requires 15–20 seconds of friction covering all
surfaces. The chain of infection includes: Infectious Agent → Reservoir → Portal of Exit → Mode of
Transmission → Portal of Entry → Susceptible Host.
