NCLEX RN Documentation Exam
Practice Test 100 Questions Plus
Correct Answers (Verified Answers)
Plus Rationales 2026
Q1. Which documentation entry is most appropriate for a nurse after
administering an oral medication?
A. Patient doing well after medication.
B. Medication given as ordered; no problems noted.
C. Administered acetaminophen 650 mg PO at 1000 for reported headache
rated 6/10.
D. Patient tolerated medication nicely.
Answer: C. Administered acetaminophen 650 mg PO at 1000 for reported
headache rated 6/10.
Rationale: Documentation should be objective, specific, and include the
medication, dose, route, time, and reason when appropriate. Vague
statements such as “doing well” are not sufficient.
Q2. Which statement best describes accurate nursing documentation?
A. It should contain the nurse's opinions about the patient.
B. It should include only abnormal findings.
C. It should be factual, objective, timely, and complete.
D. It should be completed at the end of the shift whenever possible.
Answer: C. It should be factual, objective, timely, and complete.
Rationale: Accurate documentation provides a factual record of assessment,
interventions, responses, and relevant communication.
,Q3. A nurse discovers an error in a paper medical record. What should the
nurse do?
A. Erase the incorrect information completely.
B. Cover the error with correction fluid.
C. Draw a single line through the error, enter the correct information, and
follow agency policy for authentication. D. Tear out the page and rewrite it.
Answer: C. Draw a single line through the error, enter the correct information,
and follow agency policy for authentication.
Rationale: Errors in paper records should remain identifiable. A single line
allows the original entry to remain readable while the correction is properly
documented.
Q4. Which documentation is most objective?
A. Patient appears lazy.
B. Patient seems depressed.
C. Patient is rude to staff.
D. Patient remained in bed with eyes closed and did not respond to two
verbal prompts.
Answer: D. Patient remained in bed with eyes closed and did not respond to
two verbal prompts.
Rationale: Objective documentation describes observable behaviors rather
than interpretations or judgments.
Q5. A patient reports pain as 8/10. Which documentation is best?
A. Patient has severe pain.
B. Patient is exaggerating pain.
C. Patient reports incisional pain of 8/10.
D. Patient appears uncomfortable.
Answer: C. Patient reports incisional pain of 8/10.
Rationale: Pain is subjective, so the nurse should document the patient's
reported rating and location rather than making assumptions.
,Q6. Which abbreviation should the nurse avoid because it can be
misinterpreted?
A. mL
B. PO
C. U for units
D. kg
Answer: C. U for units
Rationale: “U” can be misread as a zero or other characters and may result in
medication errors. The word “units” should be written according to accepted
documentation standards.
Q7. A nurse documents, “Patient is noncompliant with treatment.” Why is this
documentation inappropriate?
A. It is too brief.
B. It is judgmental and does not describe specific behavior.
C. It contains too much information.
D. It does not include the patient's diagnosis.
Answer: B. It is judgmental and does not describe specific behavior.
Rationale: Documentation should describe what the patient actually did. For
example, the nurse could document that the patient declined a prescribed
medication after education was provided.
Q8. Which information should be documented after a patient falls?
A. The nurse's opinion about why the patient fell.
B. The patient's presumed diagnosis.
C. Objective assessment findings, interventions, patient response, and
notifications made.
D. Only the fact that an incident report was completed.
, Answer: C. Objective assessment findings, interventions, patient response,
and notifications made.
Rationale: Following a fall, the medical record should contain factual
information about the patient's condition and care. An incident report is
handled separately according to facility policy.
Q9. A nurse administers a medication late. What should the nurse document?
A. The medication was given on time.
B. The delay should not be mentioned.
C. The actual administration time and relevant reason for the delay.
D. The scheduled time only.
Answer: C. The actual administration time and relevant reason for the delay.
Rationale: Documentation must accurately reflect what occurred. Recording a
false administration time creates an inaccurate medical record.
Q10. Which entry is most appropriate for documenting a wound?
A. Wound looks bad.
B. Wound is healing normally.
C. 2-cm × 1-cm wound to right lower leg with red wound bed and scant
serous drainage.
D. Wound appears infected.
Answer: C. 2-cm × 1-cm wound to right lower leg with red wound bed and
scant serous drainage.
Rationale: Wounds should be described using measurable and observable
characteristics rather than vague conclusions.
Q11. Which documentation practice protects patient confidentiality?
A. Discussing patient information in the elevator.
B. Leaving the electronic health record open on an unattended computer.
C. Logging out of the electronic health record when leaving the workstation.
Practice Test 100 Questions Plus
Correct Answers (Verified Answers)
Plus Rationales 2026
Q1. Which documentation entry is most appropriate for a nurse after
administering an oral medication?
A. Patient doing well after medication.
B. Medication given as ordered; no problems noted.
C. Administered acetaminophen 650 mg PO at 1000 for reported headache
rated 6/10.
D. Patient tolerated medication nicely.
Answer: C. Administered acetaminophen 650 mg PO at 1000 for reported
headache rated 6/10.
Rationale: Documentation should be objective, specific, and include the
medication, dose, route, time, and reason when appropriate. Vague
statements such as “doing well” are not sufficient.
Q2. Which statement best describes accurate nursing documentation?
A. It should contain the nurse's opinions about the patient.
B. It should include only abnormal findings.
C. It should be factual, objective, timely, and complete.
D. It should be completed at the end of the shift whenever possible.
Answer: C. It should be factual, objective, timely, and complete.
Rationale: Accurate documentation provides a factual record of assessment,
interventions, responses, and relevant communication.
,Q3. A nurse discovers an error in a paper medical record. What should the
nurse do?
A. Erase the incorrect information completely.
B. Cover the error with correction fluid.
C. Draw a single line through the error, enter the correct information, and
follow agency policy for authentication. D. Tear out the page and rewrite it.
Answer: C. Draw a single line through the error, enter the correct information,
and follow agency policy for authentication.
Rationale: Errors in paper records should remain identifiable. A single line
allows the original entry to remain readable while the correction is properly
documented.
Q4. Which documentation is most objective?
A. Patient appears lazy.
B. Patient seems depressed.
C. Patient is rude to staff.
D. Patient remained in bed with eyes closed and did not respond to two
verbal prompts.
Answer: D. Patient remained in bed with eyes closed and did not respond to
two verbal prompts.
Rationale: Objective documentation describes observable behaviors rather
than interpretations or judgments.
Q5. A patient reports pain as 8/10. Which documentation is best?
A. Patient has severe pain.
B. Patient is exaggerating pain.
C. Patient reports incisional pain of 8/10.
D. Patient appears uncomfortable.
Answer: C. Patient reports incisional pain of 8/10.
Rationale: Pain is subjective, so the nurse should document the patient's
reported rating and location rather than making assumptions.
,Q6. Which abbreviation should the nurse avoid because it can be
misinterpreted?
A. mL
B. PO
C. U for units
D. kg
Answer: C. U for units
Rationale: “U” can be misread as a zero or other characters and may result in
medication errors. The word “units” should be written according to accepted
documentation standards.
Q7. A nurse documents, “Patient is noncompliant with treatment.” Why is this
documentation inappropriate?
A. It is too brief.
B. It is judgmental and does not describe specific behavior.
C. It contains too much information.
D. It does not include the patient's diagnosis.
Answer: B. It is judgmental and does not describe specific behavior.
Rationale: Documentation should describe what the patient actually did. For
example, the nurse could document that the patient declined a prescribed
medication after education was provided.
Q8. Which information should be documented after a patient falls?
A. The nurse's opinion about why the patient fell.
B. The patient's presumed diagnosis.
C. Objective assessment findings, interventions, patient response, and
notifications made.
D. Only the fact that an incident report was completed.
, Answer: C. Objective assessment findings, interventions, patient response,
and notifications made.
Rationale: Following a fall, the medical record should contain factual
information about the patient's condition and care. An incident report is
handled separately according to facility policy.
Q9. A nurse administers a medication late. What should the nurse document?
A. The medication was given on time.
B. The delay should not be mentioned.
C. The actual administration time and relevant reason for the delay.
D. The scheduled time only.
Answer: C. The actual administration time and relevant reason for the delay.
Rationale: Documentation must accurately reflect what occurred. Recording a
false administration time creates an inaccurate medical record.
Q10. Which entry is most appropriate for documenting a wound?
A. Wound looks bad.
B. Wound is healing normally.
C. 2-cm × 1-cm wound to right lower leg with red wound bed and scant
serous drainage.
D. Wound appears infected.
Answer: C. 2-cm × 1-cm wound to right lower leg with red wound bed and
scant serous drainage.
Rationale: Wounds should be described using measurable and observable
characteristics rather than vague conclusions.
Q11. Which documentation practice protects patient confidentiality?
A. Discussing patient information in the elevator.
B. Leaving the electronic health record open on an unattended computer.
C. Logging out of the electronic health record when leaving the workstation.
