,NU 136 EXAM 3 Fundamentals of Nursing Questions And Answers
2026/2027 Galen College
Q1. Which statement best describes the primary purpose of nursing
documentation?
A) Replace communication with the healthcare team
B) Provide a record only for billing
C) Communicate patient care and provide a legal and clinical record
D) Record only abnormal findings
Correct Answer: C) Communicate patient care and provide a legal and clinical
record
Rationale: Nursing documentation communicates patient status and care
among healthcare professionals while providing a permanent clinical and
legal record.
Q2. Which chart entry is most appropriate?
A) "Patient is difficult and uncooperative."
B) "Patient refused breakfast and stated, 'I am nauseated.'"
C) "Patient seems to be exaggerating symptoms."
D) "Patient had a bad attitude this morning."
Correct Answer: B) "Patient refused breakfast and stated, 'I am nauseated.'"
Rationale: Documentation should contain objective observations and the
patient's actual statements rather than opinions, judgments, or vague
descriptions.
Q3. Which statement about the medical record is correct?
A) It may be altered whenever the nurse discovers an error.
B) It belongs to the patient physically.
C) It is a confidential record maintained by the healthcare organization.
D) It can be shared with anyone who requests it.
Correct Answer: C) It is a confidential record maintained by the healthcare
organization.
Rationale: The medical record is maintained by the healthcare organization
and must be protected according to privacy and confidentiality requirements.
Q4. Which documentation practice is appropriate when correcting a
paper-recording error?
, A) Erase the original entry completely.
B) Use correction fluid over the error.
C) Cover the error with another label.
D) Correct the error according to agency policy while preserving the original
entry.
Correct Answer: D) Correct the error according to agency policy while
preserving the original entry.
Rationale: Corrections must preserve the original information and follow
organizational procedures so the record remains an accurate legal document.
Q5. Which charting method organizes patient information around
identified problems?
A) Problem-oriented documentation
B) Source-oriented documentation
C) Narrative-only documentation
D) Chronologic-only documentation
Correct Answer: A) Problem-oriented documentation
Rationale: Problem-oriented records organize information around patient
problems, helping the healthcare team focus documentation on identified
needs and their management.
Q6. Which characteristic describes source-oriented documentation?
A) Information is organized only by diagnosis.
B) Each discipline generally documents in its own section or record.
C) All documentation is entered only electronically.
D) No chronological information is included.
Correct Answer: B) Each discipline generally documents in its own section or
record.
Rationale: In source-oriented records, documentation is organized by the
source of the information or the healthcare discipline providing the care.
Q7. Which principle should guide electronic health-record
documentation?
A) Document interventions before performing them.
B) Delay all charting until the end of the shift.
C) Document accurately and as close to the time of care as possible.
D) Copy previous entries without reassessment.
2026/2027 Galen College
Q1. Which statement best describes the primary purpose of nursing
documentation?
A) Replace communication with the healthcare team
B) Provide a record only for billing
C) Communicate patient care and provide a legal and clinical record
D) Record only abnormal findings
Correct Answer: C) Communicate patient care and provide a legal and clinical
record
Rationale: Nursing documentation communicates patient status and care
among healthcare professionals while providing a permanent clinical and
legal record.
Q2. Which chart entry is most appropriate?
A) "Patient is difficult and uncooperative."
B) "Patient refused breakfast and stated, 'I am nauseated.'"
C) "Patient seems to be exaggerating symptoms."
D) "Patient had a bad attitude this morning."
Correct Answer: B) "Patient refused breakfast and stated, 'I am nauseated.'"
Rationale: Documentation should contain objective observations and the
patient's actual statements rather than opinions, judgments, or vague
descriptions.
Q3. Which statement about the medical record is correct?
A) It may be altered whenever the nurse discovers an error.
B) It belongs to the patient physically.
C) It is a confidential record maintained by the healthcare organization.
D) It can be shared with anyone who requests it.
Correct Answer: C) It is a confidential record maintained by the healthcare
organization.
Rationale: The medical record is maintained by the healthcare organization
and must be protected according to privacy and confidentiality requirements.
Q4. Which documentation practice is appropriate when correcting a
paper-recording error?
, A) Erase the original entry completely.
B) Use correction fluid over the error.
C) Cover the error with another label.
D) Correct the error according to agency policy while preserving the original
entry.
Correct Answer: D) Correct the error according to agency policy while
preserving the original entry.
Rationale: Corrections must preserve the original information and follow
organizational procedures so the record remains an accurate legal document.
Q5. Which charting method organizes patient information around
identified problems?
A) Problem-oriented documentation
B) Source-oriented documentation
C) Narrative-only documentation
D) Chronologic-only documentation
Correct Answer: A) Problem-oriented documentation
Rationale: Problem-oriented records organize information around patient
problems, helping the healthcare team focus documentation on identified
needs and their management.
Q6. Which characteristic describes source-oriented documentation?
A) Information is organized only by diagnosis.
B) Each discipline generally documents in its own section or record.
C) All documentation is entered only electronically.
D) No chronological information is included.
Correct Answer: B) Each discipline generally documents in its own section or
record.
Rationale: In source-oriented records, documentation is organized by the
source of the information or the healthcare discipline providing the care.
Q7. Which principle should guide electronic health-record
documentation?
A) Document interventions before performing them.
B) Delay all charting until the end of the shift.
C) Document accurately and as close to the time of care as possible.
D) Copy previous entries without reassessment.
