NCLEX QUESTIONS

NCLEX QUESTIONS_ CHAPTER 26:
DOCUMENTATION AND
INFORMATICS, BOWEL
ELIMINATION, URINARY
ELIMINATION QUESTIONS WITH
CORRECT ANSWERS 2025/2026
AAnurseApreceptorAisAworkingAwithAaAstudentAnurse.AWhichAbehaviorAbyAtheAstudentAnurseAwill

requireAtheAnurseApreceptorAtoAintervene?

a.ATheAstudentAnurseAreviewsAtheApatient'sAmedicalArecord.

b.ATheAstudentAnurseAreadsAtheApatient'sAplanAofAcare.

c.ATheAstudentAnurseAsharesApatientAinformationAwithAaAfriend.

d.ATheAstudentAnurseAdocumentsAmedicationAadministeredAtoAtheApatientA-
AcorrectAanswersANS:AC



WhenAyouAareAaAstudentAinAaAclinicalAsetting,AconfidentialityAandAcomplianceAwithAtheAHealthAI
nsuranceAPortabilityAandAAccountabilityAActA(HIPAA)AareApartAofAprofessionalApractice.AWhenA
aAstudentAnurseAsharesApatientAinformationAwithAaAfriend,AconfidentialityAandAHIPAAAstandard
s

haveAbeenAviolated.AYouAcanAreviewAyourApatients'AmedicalArecordsAonlyAtoAseekAinformationA
neededAtoAprovideAsafeAandAeffectiveApatientAcare.AForAexample,AwhenAyouAareAassignedAtoAca
reAforAaApatient,AyouAneedAtoAreviewAtheApatient'sAmedicalArecordAandAplanAofAcare.AYouAdoAno
t

shareAthisAinformationAwithAclassmatesAandAyouAdoAnotAaccessAtheAmedicalArecordsAofAotherAp
atientsAonAtheAunit

AAnurseApreparedAanAaudiotapedAexchangeAwithAanotherAnurseAofAinformationAaboutAaApatien
t.

WhichAactionAdidAtheAnurseAcomplete?ATheAnurseAcompletedAa

a.AReport.

b.ARecord.

c.AConsultation.

d.AReferralA-AcorrectAanswersANS:AA

,ReportsAareAoral,Awritten,AorAaudiotapedAexchangesAofAinformationAamongAcaregivers.AAApatie
nt'sArecordAorAchartAisAaAconfidential,ApermanentAlegalAdocumentAconsistingAofAinformationAre
levantAtoAhisAorAherAhealthAcare.AConsultationsAareAanotherAformAofAdiscussionAinAwhichAone

professionalAcaregiverAgivesAformalAadviceAaboutAtheAcareAofAaApatientAtoAanotherAcaregiver.A
NursesAdocumentAreferralsA(arrangementsAforAtheAservicesAofAanotherAcareAprovider).

WhichAsituationAbestAindicatesAthatAtheAnurseAhasAaAgoodAunderstandingAregardingAauditingAa
ndAmonitoringAofApatients'AhealthArecords?

a.ATheAnurseAdeterminesAtheAdegreeAtoAwhichAstandardsAofAcareAareAmetAbyAreviewingApatient
s'AhealthArecords.

b.ATheAnurseArealizesAthatAcareAnotAdocumentedAinApatients'AhealthArecordsAstillAqualifiesAasAca
reAprovided.

c.ATheAnurseAknowsAthatAreimbursementAisAbasedAonAtheAdiagnosis-
relatedAgroupsAdocumentedAinApatients'Arecords.

d.ATheAnurseAcomparesAdataAinApatients'ArecordsAtoAdetermineAwhetherAaAnewAtreatmentAhad
AbetterAoutcomesAthanAtheAstandardAtreatment.A-AcorrectAanswersANS:AA



TheApatientArecordAisAaAvaluableAsourceAofAdataAforAallAmembersAofAtheAhealthAcareAteam.AItsAp
urposesAincludeAcommunication,AlegalAdocumentation,AfinancialAbilling,Aeducation,Aresearch,A
andAauditing/monitoring.ATheAauditing/monitoringApurposeAinvolvesAnursesAauditingArecordsA
throughoutAtheAyearAtoAdetermineAtheAdegreeAtoAwhichAstandardsAofAcareAareAmetAandAtoAide
ntifyAareasAneedingAimprovementAandAstaffAdevelopment.ATheAlegalAdocumentationApurposeAi
nvolvesAtheAconceptAthatAevenAthoughAnursingAcareAmayAhaveAbeenAexcellent,AinAaAcourtAofAla
w,A"careAnotAdocumentedAisAcareAnotAprovided."ATheAfinancialAbillingAorAreimbursementApurp
oseAinvolvesAdiagnosis-
relatedAgroupsA(DRGs)AasAtheAbasisAforAestablishingAreimbursementAforApatientAcare.AForArese
archApurposes,AtheAresearcherAcomparesAtheApatient'sArecordedAfindingsAtoAdetermineAwheth
erAtheAnewAmethodAwasAmoreAeffectiveAthanAtheAstandardAprotocol.AAnalysisAofAdataAfromAres
earchAcontributesAtoAevidence-basedAnursingApracticeAandAqualityAhealthAcare

AfterAprovidingAcare,AaAnurseAchartsAinAtheApatient'sArecord.AWhichAentryAshouldAtheAnurse

document?

a.AAppearsArestlessAwhenAsittingAinAtheAchair

b.ADrankAadequateAamountsAofAwater

c.AApparentlyAisAasleepAwithAeyesAclosed

d.ASkinApaleAandAcoolA-AcorrectAanswersANS:AD

,AAfactualArecordAcontainsAdescriptive,AobjectiveAinformationAaboutAwhatAaAnurseAsees,Ahears,A
feels,AandAsmells.AAnAobjectiveAdescriptionAisAtheAresultAofAdirectAobservationAandAmeasureme
nt.AForAexample,A"B/PA80/50,ApatientAdiaphoretic,AheartArateA102AandAregular."AAvoidAvagueAte
rmsAsuchAasAappears,Aseems,AorAapparentlyAbecauseAtheseAwordsAsuggestAthatAyouAareAstating
AanAopinion,AdoAnotAaccuratelyAcommunicateAfacts,AandAdoAnotAinformAanotherAcaregiverAofAd


etailsAregardingAbehaviorsAexhibitedAbyAtheApatient.AUseAofAexactAmeasurementsAestablishesAa
ccuracy.AForAexample,AaAdescriptionAsuchAasA"Intake,A360AmLAofAwater"AisAmoreAaccurateAthanA
"PatientAdrankAanAadequateAamountAofAfluid."

AAnurseAhasAprovidedAcareAtoAaApatient.AWhichAentryAshouldAtheAnurseAdocumentAinAtheApatie
nt's

record?

a.A"PatientAseemsAtoAbeAinApainAandAstates,A'IAfeelAuncomfortable.'"

b.AStatusAunchanged,AdoingAwell

c.ALeftAabdominalAincisionA1AinchAinAlengthAwithoutAredness,Adrainage,AorAedema

d.APatientAisAhardAtoAcareAforAandArefusesAallAtreatmentsAandAmedications.AFamilyApresentA-
AcorrectAanswersANS:AC



UseAofAexactAmeasurementsAestablishesAaccuracy.AChartingAthatAanAabdominalAwoundAisA"5Ac
mAinAlengthAwithoutAredness,Adrainage,AorAedema"AisAmoreAdescriptiveAthanA"largeAwoundAhe
alingAwell."AIncludeAobjectiveAdataAtoAsupportAsubjectiveAdata,AsoAyourAchartingAisAasAdescripti
veAasApossible.AAvoidAusingAgeneralized,AemptyAphrasesAsuchAasA"statusAunchanged"AorA"hadAa
AgoodAday."AItAisAessentialAtoAavoidAtheAuseAofAunnecessaryAwordsAandAirrelevantAdetailsAorAper


sonalAopinions.A"PatientAisAhardAtoAcareAfor"AisAaApersonalAopinionAandAshouldAbeAavoided.AItAis
AalsoAa



criticalAcommentAthatAcanAbeAusedAasAevidenceAforAnonprofessionalAbehaviorAorApoorAqualityA
ofAcare.AJustAchart,A"RefusesAallAtreatmentsAandAmedications."

AApreceptorAisAworkingAwithAaAnewAnurseAonAdocumentation.AWhichAsituationAwillAcauseAthe

preceptorAtoAintervene?

a.ATheAnewAnurseAusesAaAblackAinkApenAtoAchart.

b.ATheAnewAnurseAchartsAconsecutivelyAonAeveryAotherAline.

c.ATheAnewAnurseAendsAeachAentryAwithAsignatureAandAtitle.

d.ATheAnewAnurseAkeepsAtheApasswordAsecureA-AcorrectAanswersANS:AB

ChartAconsecutively,AlineAbyAlineA(notAeveryAotherAline);AifAspaceAisAleft,AdrawAaAlineAhorizontall
yAthroughAit,AandAsignAyourAnameAatAtheAend.AEveryAotherAlineAshouldAnotAbeAleftAblank.ARecor
dAallAentriesAlegiblyAandAinAblackAink.AEndAeachAentryAwithAyourAsignatureAandAtitle.AForAcompu

, terAdocumentation,AkeepAyourApasswordAtoAyourself.AUsingAblackAink,AendingAeachAentryAwithA
signatureAandAtitle,AandAkeepingAtheApasswordAsecureAareAallAappropriateAbehaviors

AAnurseAisAchartingAonAaApatient'sArecord.AWhichAactionAisAmostAaccurateAlegally?

a.AChartsAlegibly

b.AStatesAtheApatientAisAbelligerent

c.AUsesAcorrectionAfluidAtoAcorrectAerror

d.AWritesAentryAforAanotherAnurseA-AcorrectAanswersANS:AA

RecordAallAentriesAlegibly.ADoAnotAwriteApersonalAopinions.AEnterAonlyAobjectiveAandAfactualAo
bservationsAofApatient'sAbehavior;AquoteAallApatientAcomments.AForAexample,ApatientArefusesA
toAcoughAandAdeepAbreathe,Asaying,A"IAdon'tAcareAwhatAyouAsay,AIAwillAnotAdoAit."ADoAnotAerase,
AapplyAcorrectionAfluid,AorAscratchAoutAerrorsAmadeAwhileArecording.AChartAonlyAforAyourself



AAnurseAwantsAtoAintegrateAallApertinentApatientAinformationAintoAoneArecord,AregardlessAofAth
e

numberAofAtimesAaApatientAentersAtheAhealthAcareAsystem.AWhichAtermAshouldAtheAnurseAuseAt
o

describeAthisAsystem?

a.AElectronicAmedicalArecord

b.AElectronicAhealthArecord

c.AElectronicAchartingArecord

d.AElectronicAproblemArecordA-AcorrectAanswersANS:AB

AAuniqueAfeatureAofAanAelectronicAhealthArecordA(EHR)AisAitsAabilityAtoAintegrateAallApertinentAp
atientAinformationAintoAoneArecord,AregardlessAofAtheAnumberAofAtimesAaApatientAentersAaAheal
thAcareAsystem.AAlthoughAtheAelectronicAmedicalArecordA(EMR)AcontainsApatientAdataAgathere
dAinAa

healthAcareAsettingAatAaAspecificAtimeAandAplaceAandAisAaApartAofAtheAEHR,AtheAtwoAtermsAareAfr
equentlyAusedAinterchangeably.AThereAareAnoAsuchAtermsAasAelectronicAchartingArecordAorAele
ctronicAproblemArecord

AAnurseAhasAtaughtAtheApatientAhowAtoAuseAcrutches.ATheApatientAwentAupAandAdownAtheAstair
s

usingAcrutchesAwithAnoAdifficulties.AWhichAinformationAwillAtheAnurseAuseAforAtheA"I"AinAPIE

charting?

a.APatientAwentAupAandAdownAstairs