NCLEX Practice Exam Questions Documentation
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Terms in this set (88)
Documentation is: A
A) Anything written or printed that
you rely on as record or proof for
authorized persons.
B) Lab results for a patient you are
taking care of.
C) Admission paperwork for billing
purposes.
D) Instructions from the attending
doctor.
,A nurse preceptor is working with a ANS: C
student nurse. Which behavior by When you are a student in a clinical setting,
the student nurse will confidentiality and compliance with the Health
require the nurse preceptor to Insurance Portability and Accountability Act
intervene? (HIPAA) are part of professional practice. When a
a. The student nurse reviews the student nurse shares patient information with a
patient's medical record. friend, confidentiality and HIPAA standards
b. The student nurse reads the have been violated. You can review your patients'
patient's plan of care. medical records only to seek information needed
c. The student nurse shares patient to provide safe and effective patient care. For
information with a friend. example, when you are assigned to care for a
d. The student nurse documents patient, you need to review the patient's medical
medication administered to the record and plan of care. You do not
patient share this information with classmates and you do
not access the medical records of other patients
on the unit
Accreditation is: C
A) Certification by the ANA.
B) Medicare approval.
C) Joint Commission specifies
guidelines for documentation.
D) Passing the NCLEX.
,A nurse prepared an audiotaped ANS: A
exchange with another nurse of Reports are oral, written, or audiotaped
information about a patient. exchanges of information among caregivers. A
Which action did the nurse patient's record or chart is a confidential,
complete? The nurse completed a permanent legal document consisting of
a. Report. information relevant to his or her health care.
b. Record. Consultations are another form of discussion in
c. Consultation. which one
d. Referral professional caregiver gives formal advice about
the care of a patient to another caregiver. Nurses
document referrals (arrangements for the
services of another care provider).
Which of the following is correctly D: reason you need to document pt. exact words
charted according to the six in quotations when recording subjective data.
guidelines for quality recording?
A: "Was depressed today"
B:"respirations rapid; lung sounds
clear"
C:"Had a good day. Up and about
in room."
D:"Crying. States she does not want
visitors to see her like this"
Explain the new rights for clients B, C, D, E
related to HIPPA.
A) Patient right to leave healthcare
facility.
B) Patient education on privacy
protections
C) Patient's right to access their
medical records.
D) Provider must receive consent
from patient before releasing
information.
E) Recourse options if privacy
protections are violated.
, Which situation best indicates that ANS: A
the nurse has a good The patient record is a valuable source of data
understanding regarding auditing for all members of the health care team. Its
and monitoring of patients' health purposes include communication, legal
records? documentation, financial billing, education,
a. The nurse determines the degree research, and auditing/monitoring. The
to which standards of care are met auditing/monitoring purpose involves nurses
by reviewing patients' health auditing records throughout the year to
records. determine the degree to which standards of care
b. The nurse realizes that care not are met and to identify areas needing
documented in patients' health improvement and staff development. The legal
records still qualifies as care documentation purpose involves the concept
provided. that even though nursing care may have been
c. The nurse knows that excellent, in a court of law, "care not documented
reimbursement is based on the is care not provided." The financial billing or
diagnosis-related groups reimbursement purpose involves diagnosis-
documented in patients' records. related groups (DRGs) as the basis for
d. The nurse compares data in establishing reimbursement for patient care. For
patients' records to determine research purposes, the researcher compares the
whether a new treatment had better patient's recorded findings to determine whether
outcomes than the standard the new method was more effective than the
treatment. standard protocol. Analysis of data from research
contributes to evidence-based nursing practice
and quality health care
The standards of documentation by D
the Joint Commission require:
A) Narrative on how patient was
cared for.
B) Patient's vital signs every 4 hours.
C) A resolution date for all planned
outcomes.
D) Documentation within the
context of the nursing process, as
well as evidence of client and
family teaching and discharge
planning.
Latest 2026 Actual Questions and Verified
Answers () A+ Grade 100%
Guarantee Verified by Experts
Save
Terms in this set (88)
Documentation is: A
A) Anything written or printed that
you rely on as record or proof for
authorized persons.
B) Lab results for a patient you are
taking care of.
C) Admission paperwork for billing
purposes.
D) Instructions from the attending
doctor.
,A nurse preceptor is working with a ANS: C
student nurse. Which behavior by When you are a student in a clinical setting,
the student nurse will confidentiality and compliance with the Health
require the nurse preceptor to Insurance Portability and Accountability Act
intervene? (HIPAA) are part of professional practice. When a
a. The student nurse reviews the student nurse shares patient information with a
patient's medical record. friend, confidentiality and HIPAA standards
b. The student nurse reads the have been violated. You can review your patients'
patient's plan of care. medical records only to seek information needed
c. The student nurse shares patient to provide safe and effective patient care. For
information with a friend. example, when you are assigned to care for a
d. The student nurse documents patient, you need to review the patient's medical
medication administered to the record and plan of care. You do not
patient share this information with classmates and you do
not access the medical records of other patients
on the unit
Accreditation is: C
A) Certification by the ANA.
B) Medicare approval.
C) Joint Commission specifies
guidelines for documentation.
D) Passing the NCLEX.
,A nurse prepared an audiotaped ANS: A
exchange with another nurse of Reports are oral, written, or audiotaped
information about a patient. exchanges of information among caregivers. A
Which action did the nurse patient's record or chart is a confidential,
complete? The nurse completed a permanent legal document consisting of
a. Report. information relevant to his or her health care.
b. Record. Consultations are another form of discussion in
c. Consultation. which one
d. Referral professional caregiver gives formal advice about
the care of a patient to another caregiver. Nurses
document referrals (arrangements for the
services of another care provider).
Which of the following is correctly D: reason you need to document pt. exact words
charted according to the six in quotations when recording subjective data.
guidelines for quality recording?
A: "Was depressed today"
B:"respirations rapid; lung sounds
clear"
C:"Had a good day. Up and about
in room."
D:"Crying. States she does not want
visitors to see her like this"
Explain the new rights for clients B, C, D, E
related to HIPPA.
A) Patient right to leave healthcare
facility.
B) Patient education on privacy
protections
C) Patient's right to access their
medical records.
D) Provider must receive consent
from patient before releasing
information.
E) Recourse options if privacy
protections are violated.
, Which situation best indicates that ANS: A
the nurse has a good The patient record is a valuable source of data
understanding regarding auditing for all members of the health care team. Its
and monitoring of patients' health purposes include communication, legal
records? documentation, financial billing, education,
a. The nurse determines the degree research, and auditing/monitoring. The
to which standards of care are met auditing/monitoring purpose involves nurses
by reviewing patients' health auditing records throughout the year to
records. determine the degree to which standards of care
b. The nurse realizes that care not are met and to identify areas needing
documented in patients' health improvement and staff development. The legal
records still qualifies as care documentation purpose involves the concept
provided. that even though nursing care may have been
c. The nurse knows that excellent, in a court of law, "care not documented
reimbursement is based on the is care not provided." The financial billing or
diagnosis-related groups reimbursement purpose involves diagnosis-
documented in patients' records. related groups (DRGs) as the basis for
d. The nurse compares data in establishing reimbursement for patient care. For
patients' records to determine research purposes, the researcher compares the
whether a new treatment had better patient's recorded findings to determine whether
outcomes than the standard the new method was more effective than the
treatment. standard protocol. Analysis of data from research
contributes to evidence-based nursing practice
and quality health care
The standards of documentation by D
the Joint Commission require:
A) Narrative on how patient was
cared for.
B) Patient's vital signs every 4 hours.
C) A resolution date for all planned
outcomes.
D) Documentation within the
context of the nursing process, as
well as evidence of client and
family teaching and discharge
planning.
