___________________________________________________________________
Nursing 354 Documentation Exam
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A
Instant Download Pdf
___________________________________________________________________
1. Which principle is most important when documenting nursing care?
A. Document care before providing it
B. Use vague language to save time
C. Record accurate, timely, and objective information
D. Document only abnormal findings
Answer: C. Accurate, timely, and objective information
Rationale: Documentation should accurately reflect the patient's condition and
care provided. Timely and objective charting promotes continuity of care and
patient safety.
2. Which entry is most appropriate for a patient's pain assessment?
A. Patient seems uncomfortable
B. Patient states, "My pain is 7 out of 10"
C. Patient is having terrible pain
D. Patient appears to be exaggerating pain
Answer: B. Patient states, "My pain is 7 out of 10"
,Rationale: This documentation uses the patient's own report and provides a
measurable pain rating without judgment.
3. When should a nurse document a medication administration?
A. Before administering the medication
B. At the end of the shift
C. Immediately after administration according to policy
D. Only if the patient experiences an adverse effect
Answer: C. Immediately after administration according to policy
Rationale: Documentation should occur promptly after medication
administration to reduce errors and accurately communicate what was given.
4. Which documentation is objective?
A. Patient is rude
B. Patient appears lazy
C. Patient states, "I feel dizzy"
D. Patient is probably anxious
Answer: C. Patient states, "I feel dizzy"
Rationale: The statement records the patient's reported symptom without
adding an unsupported interpretation.
5. A nurse realizes that an incorrect statement was entered into a paper
medical record. What should the nurse do?
A. Erase the entry completely
B. Cover the entry with correction fluid
C. Follow agency policy for correcting documentation
D. Tear out the page
Answer: C. Follow agency policy for correcting documentation
Rationale: Altering the medical record improperly can compromise its legal
integrity. Corrections must follow organizational policy and applicable
regulations.
, 6. Which abbreviation should a nurse avoid because it may be misinterpreted?
A. mL
B. kg
C. U
D. L
Answer: C. U
Rationale: The abbreviation "U" for units can be misread as a number or other
abbreviation. Approved terminology should be used instead.
7. What is the primary purpose of nursing documentation?
A. To protect the hospital from complaints
B. To communicate patient information and care
C. To reduce the nurse's workload
D. To replace verbal communication entirely
Answer: B. To communicate patient information and care
Rationale: Documentation provides a permanent record of assessment findings,
interventions, responses, and communication relevant to patient care.
8. Which statement represents appropriate charting?
A. Patient had a bad night
B. Patient was difficult
C. Patient ambulated 50 feet with a walker and one-person assistance
D. Patient tolerated everything well
Answer: C. Patient ambulated 50 feet with a walker and one-person assistance
Rationale: This entry is specific, measurable, and objective.
9. What should a nurse do when documenting a patient's refusal of
treatment?
A. Document only that the treatment was not completed
B. Document the refusal, relevant education, and patient's response
C. Delete the treatment order
D. Document that the patient was noncompliant
, Answer: B. Document the refusal, relevant education, and patient's response
Rationale: Complete documentation should identify the refusal, education
provided, patient's stated concerns when appropriate, and notifications or
follow-up required.
10.Which information should be included when documenting a change in
patient condition?
A. Only the nurse's opinion
B. Assessment findings, interventions, and patient response
C. Only the physician's name
D. Only the patient's diagnosis
Answer: B. Assessment findings, interventions, and patient response
Rationale: Documentation of a change in condition should provide a clear
clinical picture and record the actions taken and resulting response.
11.Which documentation method organizes information into subjective,
objective, assessment, and plan categories?
A. PIE
B. SOAP
C. MAR
D. Kardex
Answer: B. SOAP
Rationale: SOAP stands for Subjective, Objective, Assessment, and Plan and is a
structured approach to clinical documentation.
12.Which statement is subjective data?
A. Temperature is 38.2°C
B. Blood pressure is 148/88 mmHg
C. Wound measures 3 cm
D. Patient states, "I feel nauseated"
Answer: D. Patient states, "I feel nauseated"
Nursing 354 Documentation Exam
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A
Instant Download Pdf
___________________________________________________________________
1. Which principle is most important when documenting nursing care?
A. Document care before providing it
B. Use vague language to save time
C. Record accurate, timely, and objective information
D. Document only abnormal findings
Answer: C. Accurate, timely, and objective information
Rationale: Documentation should accurately reflect the patient's condition and
care provided. Timely and objective charting promotes continuity of care and
patient safety.
2. Which entry is most appropriate for a patient's pain assessment?
A. Patient seems uncomfortable
B. Patient states, "My pain is 7 out of 10"
C. Patient is having terrible pain
D. Patient appears to be exaggerating pain
Answer: B. Patient states, "My pain is 7 out of 10"
,Rationale: This documentation uses the patient's own report and provides a
measurable pain rating without judgment.
3. When should a nurse document a medication administration?
A. Before administering the medication
B. At the end of the shift
C. Immediately after administration according to policy
D. Only if the patient experiences an adverse effect
Answer: C. Immediately after administration according to policy
Rationale: Documentation should occur promptly after medication
administration to reduce errors and accurately communicate what was given.
4. Which documentation is objective?
A. Patient is rude
B. Patient appears lazy
C. Patient states, "I feel dizzy"
D. Patient is probably anxious
Answer: C. Patient states, "I feel dizzy"
Rationale: The statement records the patient's reported symptom without
adding an unsupported interpretation.
5. A nurse realizes that an incorrect statement was entered into a paper
medical record. What should the nurse do?
A. Erase the entry completely
B. Cover the entry with correction fluid
C. Follow agency policy for correcting documentation
D. Tear out the page
Answer: C. Follow agency policy for correcting documentation
Rationale: Altering the medical record improperly can compromise its legal
integrity. Corrections must follow organizational policy and applicable
regulations.
, 6. Which abbreviation should a nurse avoid because it may be misinterpreted?
A. mL
B. kg
C. U
D. L
Answer: C. U
Rationale: The abbreviation "U" for units can be misread as a number or other
abbreviation. Approved terminology should be used instead.
7. What is the primary purpose of nursing documentation?
A. To protect the hospital from complaints
B. To communicate patient information and care
C. To reduce the nurse's workload
D. To replace verbal communication entirely
Answer: B. To communicate patient information and care
Rationale: Documentation provides a permanent record of assessment findings,
interventions, responses, and communication relevant to patient care.
8. Which statement represents appropriate charting?
A. Patient had a bad night
B. Patient was difficult
C. Patient ambulated 50 feet with a walker and one-person assistance
D. Patient tolerated everything well
Answer: C. Patient ambulated 50 feet with a walker and one-person assistance
Rationale: This entry is specific, measurable, and objective.
9. What should a nurse do when documenting a patient's refusal of
treatment?
A. Document only that the treatment was not completed
B. Document the refusal, relevant education, and patient's response
C. Delete the treatment order
D. Document that the patient was noncompliant
, Answer: B. Document the refusal, relevant education, and patient's response
Rationale: Complete documentation should identify the refusal, education
provided, patient's stated concerns when appropriate, and notifications or
follow-up required.
10.Which information should be included when documenting a change in
patient condition?
A. Only the nurse's opinion
B. Assessment findings, interventions, and patient response
C. Only the physician's name
D. Only the patient's diagnosis
Answer: B. Assessment findings, interventions, and patient response
Rationale: Documentation of a change in condition should provide a clear
clinical picture and record the actions taken and resulting response.
11.Which documentation method organizes information into subjective,
objective, assessment, and plan categories?
A. PIE
B. SOAP
C. MAR
D. Kardex
Answer: B. SOAP
Rationale: SOAP stands for Subjective, Objective, Assessment, and Plan and is a
structured approach to clinical documentation.
12.Which statement is subjective data?
A. Temperature is 38.2°C
B. Blood pressure is 148/88 mmHg
C. Wound measures 3 cm
D. Patient states, "I feel nauseated"
Answer: D. Patient states, "I feel nauseated"
