,NU 137 Exam 3 Fundamentals of Nursing Questions And Answers
2026/2027 Galen College
Q1. Which is a primary purpose of nursing documentation?
A) Provide a legal and clinical record of patient care
B) Replace all verbal communication
C) Entertain other healthcare professionals
D) Record the nurse's personal opinions
Correct Answer: A) Provide a legal and clinical record of patient care
Rationale: Nursing documentation communicates patient status, care
provided, responses to interventions, and important information for
continuity and legal accountability.
Q2. Which documentation entry is most appropriate?
A) “Patient is difficult and uncooperative.”
B) “Patient appears lazy today.”
C) “Patient refused ambulation and stated, ‘I feel too weak.’”
D) “Patient is probably depressed.”
Correct Answer: C) “Patient refused ambulation and stated, ‘I feel too weak.’”
Rationale: Documentation should contain objective observations and the
patient's own statements rather than judgmental or unsupported
conclusions.
Q3. Which documentation practice is inappropriate?
A) Recording patient responses to interventions
B) Documenting care promptly
C) Documenting an intervention before performing it
D) Recording objective assessment findings
Correct Answer: C) Documenting an intervention before performing it
Rationale: Documentation must accurately reflect care that has actually been
provided. Precharting creates an inaccurate medical record.
Q4. What does the phrase “if it wasn't documented, it wasn't done”
emphasize?
A) The legal and communication importance of accurate documentation
B) Documentation is optional
, C) Verbal communication is unnecessary
D) Nurses should document every possible assumption
Correct Answer: A) The legal and communication importance of accurate
documentation
Rationale: The medical record serves as an important legal and clinical
record, so care must be accurately and promptly documented.
Q5. Which abbreviation should the nurse avoid using because it may
be misinterpreted?
A) mL
B) mg
C) U for units
D) L
Correct Answer: C) U for units
Rationale: The abbreviation “U” may be misread as a zero or other
characters and can contribute to medication errors.
Q6. Which documentation statement is objective?
A) “Patient is anxious.”
B) “Patient looks terrible.”
C) “Patient pacing in room and states, ‘I cannot relax.’”
D) “Patient is acting strangely.”
Correct Answer: C) “Patient pacing in room and states, ‘I cannot relax.’”
Rationale: Objective documentation describes observable behavior and
includes the patient's actual statement without unsupported interpretation.
Q7. Which information should be included when documenting a
patient's response to pain medication?
A) Only that the medication was given
B) The patient's pain level before and after the intervention
C) The nurse's opinion of the medication
D) The patient's diagnosis only
Correct Answer: B) The patient's pain level before and after the intervention
Rationale: Documentation should demonstrate the intervention and the
patient's measurable response so effectiveness can be evaluated.
2026/2027 Galen College
Q1. Which is a primary purpose of nursing documentation?
A) Provide a legal and clinical record of patient care
B) Replace all verbal communication
C) Entertain other healthcare professionals
D) Record the nurse's personal opinions
Correct Answer: A) Provide a legal and clinical record of patient care
Rationale: Nursing documentation communicates patient status, care
provided, responses to interventions, and important information for
continuity and legal accountability.
Q2. Which documentation entry is most appropriate?
A) “Patient is difficult and uncooperative.”
B) “Patient appears lazy today.”
C) “Patient refused ambulation and stated, ‘I feel too weak.’”
D) “Patient is probably depressed.”
Correct Answer: C) “Patient refused ambulation and stated, ‘I feel too weak.’”
Rationale: Documentation should contain objective observations and the
patient's own statements rather than judgmental or unsupported
conclusions.
Q3. Which documentation practice is inappropriate?
A) Recording patient responses to interventions
B) Documenting care promptly
C) Documenting an intervention before performing it
D) Recording objective assessment findings
Correct Answer: C) Documenting an intervention before performing it
Rationale: Documentation must accurately reflect care that has actually been
provided. Precharting creates an inaccurate medical record.
Q4. What does the phrase “if it wasn't documented, it wasn't done”
emphasize?
A) The legal and communication importance of accurate documentation
B) Documentation is optional
, C) Verbal communication is unnecessary
D) Nurses should document every possible assumption
Correct Answer: A) The legal and communication importance of accurate
documentation
Rationale: The medical record serves as an important legal and clinical
record, so care must be accurately and promptly documented.
Q5. Which abbreviation should the nurse avoid using because it may
be misinterpreted?
A) mL
B) mg
C) U for units
D) L
Correct Answer: C) U for units
Rationale: The abbreviation “U” may be misread as a zero or other
characters and can contribute to medication errors.
Q6. Which documentation statement is objective?
A) “Patient is anxious.”
B) “Patient looks terrible.”
C) “Patient pacing in room and states, ‘I cannot relax.’”
D) “Patient is acting strangely.”
Correct Answer: C) “Patient pacing in room and states, ‘I cannot relax.’”
Rationale: Objective documentation describes observable behavior and
includes the patient's actual statement without unsupported interpretation.
Q7. Which information should be included when documenting a
patient's response to pain medication?
A) Only that the medication was given
B) The patient's pain level before and after the intervention
C) The nurse's opinion of the medication
D) The patient's diagnosis only
Correct Answer: B) The patient's pain level before and after the intervention
Rationale: Documentation should demonstrate the intervention and the
patient's measurable response so effectiveness can be evaluated.
