RN Documentation & Legal/Ethical
Competency Exam — Code: RN-LEGAL-
COMP | 100-Question Advanced
Practice Exam 2026 | Questions &
Answers with Detailed Rationales |
Complete Exam Prep & Study Guide
1. A nurse realizes that an incorrect blood pressure was documented in the
electronic health record 30 minutes earlier. What is the most appropriate
action?
A. Delete the incorrect entry and enter the correct blood pressure.
B. Ask another nurse to correct the entry.
C. Correct the documentation according to the EHR's amendment procedure
while preserving the original entry and documenting the correction.
D. Leave the entry unchanged because the error did not affect treatment.
Answer: C. Correct the documentation according to the EHR's amendment
procedure while preserving the original entry and documenting the correction.
,Rationale: Documentation errors should be corrected transparently according to
institutional policy. The original information should remain traceable, and
nurses should never delete, obscure, or falsify a clinical record.
2. A nurse documents, "Patient is difficult and noncompliant with treatment."
Which documentation principle is most clearly violated?
A. Timeliness
B. Confidentiality
C. Completeness
D. Objectivity
Answer: D. Objectivity
Rationale: Nursing documentation should contain objective, observable findings
rather than judgmental labels. The nurse should document specific behaviors,
such as "Patient declined the prescribed medication after risks and benefits
were explained."
3. A competent adult patient refuses a recommended surgical procedure
despite understanding the potential consequences. Which ethical principle
primarily supports the patient's decision?
A. Beneficence
B. Justice
C. Fidelity
D. Autonomy
Answer: D. Autonomy
Rationale: Autonomy recognizes a competent patient's right to make informed
decisions about their own healthcare, including refusing recommended
treatment.
4. A nurse discovers that a colleague documented administration of a
medication that the colleague actually forgot to give. What is the nurse's
priority action?
,A. Ignore the situation because the colleague is responsible for the
documentation.
B. Immediately confront the colleague in front of the patient.
C. Address the discrepancy promptly through the appropriate patient-safety and
reporting process.
D. Change the colleague's documentation to reflect the medication was not given.
Answer: C. Address the discrepancy promptly through the appropriate patient-
safety and reporting process.
Rationale: Falsified medication documentation creates a significant patient-
safety and legal concern. The discrepancy should be escalated according to
policy, and the record should not be altered by another nurse.
5. Which statement best describes informed consent?
A. The nurse is responsible for explaining every surgical risk.
B. Signing the consent form automatically proves the patient understands the
procedure.
C. The patient receives sufficient information about the proposed intervention,
including relevant risks, benefits, and alternatives, and voluntarily agrees.
D. Consent is valid only when the patient's family agrees.
Answer: C. The patient receives sufficient information about the proposed
intervention, including relevant risks, benefits, and alternatives, and voluntarily
agrees.
Rationale: Informed consent requires adequate disclosure, patient
understanding, voluntariness, and decision-making capacity. The practitioner
performing the procedure generally has responsibility for explaining the
procedure and its material risks and alternatives.
6. A patient tells a nurse, "I do not understand why I need this procedure."
What should the nurse do?
A. Tell the patient to sign because the physician already explained it.
B. Explain the procedure beyond the nurse's scope.
, C. Pause the consent process and notify the appropriate practitioner that the
patient needs further explanation.
D. Ask a family member to explain the procedure.
Answer: C. Pause the consent process and notify the appropriate practitioner
that the patient needs further explanation.
Rationale: A patient's statement that they do not understand indicates that
informed consent may not yet be established. The nurse should advocate for
clarification rather than pressure the patient to sign.
7. A nurse enters a patient's room and finds the patient unresponsive after
receiving an opioid. The nurse administers naloxone and initiates
emergency interventions. When documenting the event, which approach is
best?
A. Document only that naloxone was given.
B. Document the event at the end of the shift from memory.
C. Document objective assessment findings, interventions, patient response,
notifications, and relevant times as soon as possible.
D. Document that the opioid "caused" the respiratory arrest.
Answer: C. Document objective assessment findings, interventions, patient
response, notifications, and relevant times as soon as possible.
Rationale: Legal documentation should establish a chronological, objective
account of assessment, intervention, response, and communication. Causal
conclusions should not be documented unless clinically established and
appropriate.
8. A nurse receives a verbal medication order during an emergency. Which
action best promotes safe and legally defensible practice?
A. Administer the medication without repeating the order.
B. Ask another nurse to interpret the order.
C. Read back the order to the prescriber for verification and document it
Competency Exam — Code: RN-LEGAL-
COMP | 100-Question Advanced
Practice Exam 2026 | Questions &
Answers with Detailed Rationales |
Complete Exam Prep & Study Guide
1. A nurse realizes that an incorrect blood pressure was documented in the
electronic health record 30 minutes earlier. What is the most appropriate
action?
A. Delete the incorrect entry and enter the correct blood pressure.
B. Ask another nurse to correct the entry.
C. Correct the documentation according to the EHR's amendment procedure
while preserving the original entry and documenting the correction.
D. Leave the entry unchanged because the error did not affect treatment.
Answer: C. Correct the documentation according to the EHR's amendment
procedure while preserving the original entry and documenting the correction.
,Rationale: Documentation errors should be corrected transparently according to
institutional policy. The original information should remain traceable, and
nurses should never delete, obscure, or falsify a clinical record.
2. A nurse documents, "Patient is difficult and noncompliant with treatment."
Which documentation principle is most clearly violated?
A. Timeliness
B. Confidentiality
C. Completeness
D. Objectivity
Answer: D. Objectivity
Rationale: Nursing documentation should contain objective, observable findings
rather than judgmental labels. The nurse should document specific behaviors,
such as "Patient declined the prescribed medication after risks and benefits
were explained."
3. A competent adult patient refuses a recommended surgical procedure
despite understanding the potential consequences. Which ethical principle
primarily supports the patient's decision?
A. Beneficence
B. Justice
C. Fidelity
D. Autonomy
Answer: D. Autonomy
Rationale: Autonomy recognizes a competent patient's right to make informed
decisions about their own healthcare, including refusing recommended
treatment.
4. A nurse discovers that a colleague documented administration of a
medication that the colleague actually forgot to give. What is the nurse's
priority action?
,A. Ignore the situation because the colleague is responsible for the
documentation.
B. Immediately confront the colleague in front of the patient.
C. Address the discrepancy promptly through the appropriate patient-safety and
reporting process.
D. Change the colleague's documentation to reflect the medication was not given.
Answer: C. Address the discrepancy promptly through the appropriate patient-
safety and reporting process.
Rationale: Falsified medication documentation creates a significant patient-
safety and legal concern. The discrepancy should be escalated according to
policy, and the record should not be altered by another nurse.
5. Which statement best describes informed consent?
A. The nurse is responsible for explaining every surgical risk.
B. Signing the consent form automatically proves the patient understands the
procedure.
C. The patient receives sufficient information about the proposed intervention,
including relevant risks, benefits, and alternatives, and voluntarily agrees.
D. Consent is valid only when the patient's family agrees.
Answer: C. The patient receives sufficient information about the proposed
intervention, including relevant risks, benefits, and alternatives, and voluntarily
agrees.
Rationale: Informed consent requires adequate disclosure, patient
understanding, voluntariness, and decision-making capacity. The practitioner
performing the procedure generally has responsibility for explaining the
procedure and its material risks and alternatives.
6. A patient tells a nurse, "I do not understand why I need this procedure."
What should the nurse do?
A. Tell the patient to sign because the physician already explained it.
B. Explain the procedure beyond the nurse's scope.
, C. Pause the consent process and notify the appropriate practitioner that the
patient needs further explanation.
D. Ask a family member to explain the procedure.
Answer: C. Pause the consent process and notify the appropriate practitioner
that the patient needs further explanation.
Rationale: A patient's statement that they do not understand indicates that
informed consent may not yet be established. The nurse should advocate for
clarification rather than pressure the patient to sign.
7. A nurse enters a patient's room and finds the patient unresponsive after
receiving an opioid. The nurse administers naloxone and initiates
emergency interventions. When documenting the event, which approach is
best?
A. Document only that naloxone was given.
B. Document the event at the end of the shift from memory.
C. Document objective assessment findings, interventions, patient response,
notifications, and relevant times as soon as possible.
D. Document that the opioid "caused" the respiratory arrest.
Answer: C. Document objective assessment findings, interventions, patient
response, notifications, and relevant times as soon as possible.
Rationale: Legal documentation should establish a chronological, objective
account of assessment, intervention, response, and communication. Causal
conclusions should not be documented unless clinically established and
appropriate.
8. A nurse receives a verbal medication order during an emergency. Which
action best promotes safe and legally defensible practice?
A. Administer the medication without repeating the order.
B. Ask another nurse to interpret the order.
C. Read back the order to the prescriber for verification and document it
