NCLEX Practice Exam Questions and Answers
Documentation
1.Documentation is:
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
ANS A
2.A nurse preceptor is working with a student nurse. Which behavior by
the student nurse will
require the nurse preceptor to intervene?
a. The student nurse reviews the patient's medical record.
b. The student nurse reads the patient's plan of care.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient
ANS C
When you are a student in a clinical setting, confidentiality and
compliance with the Health Insurance Portability and Accountability Act
(HIPAA) are part of professional practice. When a student nurse shares
patient information with a friend, confiden- tiality and HIPAA standards
have been violated. You can review your patients' medical records only
,to seek information needed to provide safe and effective patient care.
For example, when you are assigned to care for a patient, you need to
review the patient's medical record and plan of care. You do not
share this information with classmates and you do not access the
medical records of other patients on the unit
3.Accreditation is:
A) Certification by the ANA.
B) Medicare approval.
C) Joint Commission specifies guidelines for documentation.
D) Passing the NCLEX
ANS C
4.A nurse prepared an audiotaped exchange with another nurse of
informa- tion about a patient.
Which action did the nurse complete? The nurse completed a
a. Report.
b. Record.
c. Consultation.
d. Referral
ANS A
Reports are oral, written, or audiotaped exchanges of information among
caregivers. A patient's record or chart is a confidential, permanent legal
document consisting of information relevant to his or her health care.
Consultations are another form of
,discussion in which one
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).
5.Which of the following is correctly charted according to the six
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":
ANS D: reason you need to document pt. exact words in quotations when
recording subjective data.
6.Explain the new rights for clients 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
ANS B, C, D, E
7.Which situation best indicates that the nurse has a good
understanding regarding auditing and monitoring of patients' health
records?
, a. The nurse determines the degree to which standards of care are met
by reviewing patients' health records.
b.The nurse realizes that care not documented in patients' health records
still qualifies as care provided.
c. The nurse knows that reimbursement is based on the diagnosis-
related groups documented in patients' records.
d. The nurse compares data in patients' records to determine whether a
new treatment had better outcomes than the standard treatment
ANS ANS: A
The patient record is a valuable source of data for all members of the
health care team. Its purposes include communication, legal
documentation, financial billing, education, research, and
auditing/monitoring. The auditing/monitoring purpose in- volves nurses
auditing records throughout the year to determine the degree to which
standards of care are met and to identify areas needing improvement
and staff development. The legal documentation purpose involves the
concept that even though nursing care may have been excellent, in a
court of law, "care not document- ed is care not provided." The financial
billing or reimbursement purpose involves diagnosis-related groups
(DRGs) as the basis for establishing reimbursement for patient care. For
research purposes, the researcher compares the patient's recorded
findings to determine whether the new method was more effective than
the standard
protocol. Analysis of data from research contributes to evidence-based
nursing practice and quality health care
Documentation
1.Documentation is:
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
ANS A
2.A nurse preceptor is working with a student nurse. Which behavior by
the student nurse will
require the nurse preceptor to intervene?
a. The student nurse reviews the patient's medical record.
b. The student nurse reads the patient's plan of care.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient
ANS C
When you are a student in a clinical setting, confidentiality and
compliance with the Health Insurance Portability and Accountability Act
(HIPAA) are part of professional practice. When a student nurse shares
patient information with a friend, confiden- tiality and HIPAA standards
have been violated. You can review your patients' medical records only
,to seek information needed to provide safe and effective patient care.
For example, when you are assigned to care for a patient, you need to
review the patient's medical record and plan of care. You do not
share this information with classmates and you do not access the
medical records of other patients on the unit
3.Accreditation is:
A) Certification by the ANA.
B) Medicare approval.
C) Joint Commission specifies guidelines for documentation.
D) Passing the NCLEX
ANS C
4.A nurse prepared an audiotaped exchange with another nurse of
informa- tion about a patient.
Which action did the nurse complete? The nurse completed a
a. Report.
b. Record.
c. Consultation.
d. Referral
ANS A
Reports are oral, written, or audiotaped exchanges of information among
caregivers. A patient's record or chart is a confidential, permanent legal
document consisting of information relevant to his or her health care.
Consultations are another form of
,discussion in which one
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).
5.Which of the following is correctly charted according to the six
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":
ANS D: reason you need to document pt. exact words in quotations when
recording subjective data.
6.Explain the new rights for clients 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
ANS B, C, D, E
7.Which situation best indicates that the nurse has a good
understanding regarding auditing and monitoring of patients' health
records?
, a. The nurse determines the degree to which standards of care are met
by reviewing patients' health records.
b.The nurse realizes that care not documented in patients' health records
still qualifies as care provided.
c. The nurse knows that reimbursement is based on the diagnosis-
related groups documented in patients' records.
d. The nurse compares data in patients' records to determine whether a
new treatment had better outcomes than the standard treatment
ANS ANS: A
The patient record is a valuable source of data for all members of the
health care team. Its purposes include communication, legal
documentation, financial billing, education, research, and
auditing/monitoring. The auditing/monitoring purpose in- volves nurses
auditing records throughout the year to determine the degree to which
standards of care are met and to identify areas needing improvement
and staff development. The legal documentation purpose involves the
concept that even though nursing care may have been excellent, in a
court of law, "care not document- ed is care not provided." The financial
billing or reimbursement purpose involves diagnosis-related groups
(DRGs) as the basis for establishing reimbursement for patient care. For
research purposes, the researcher compares the patient's recorded
findings to determine whether the new method was more effective than
the standard
protocol. Analysis of data from research contributes to evidence-based
nursing practice and quality health care
