CLINICAL PROCEDURES FOR SAFER PATIENT CARE BY GLYNDA
DOYLE AND JODIE MCCUTCHEON (BCCAMPUS) 10th EDITION 2025
TEST BANK
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, CHAPTER 8– DOCUMENTATION & LEGAL PRACTICE (25 NCLEX QS +
RATIONALES)
1. What is the most legally defensible method of documentation?
A. Verbal report
B. Abbreviated flow sheets
C. Objective, factual, timely charting
D. Charting by exception only
Answer: C
Rationale: Legal charting must be accurate, objective, and timely.
2. If a nurse makes an error in documentation, the correct action is to:
A. Erase it completely
B. Use white-out
C. Draw a single line through it and initial
D. Ask another nurse to rewrite it
Answer: C
Rationale: Corrections must be clearly marked and initialed to maintain legal integrity.
3. A patient refuses a treatment. What must the nurse do next?
A. Document the refusal and inform the provider
B. Re-attempt the treatment later
C. Persuade the patient
D. Leave it undocumented to avoid conflict
Answer: A
Rationale: Patient autonomy requires honoring refusal, with proper documentation and
reporting.
4. What does “charting by exception” mean?
A. Documenting only abnormal findings
B. Writing only every other shift
C. Documenting verbally
D. Skipping repetitive tasks
Answer: A
Rationale: Only deviations from normal are recorded.
Found this useful? Please leave a review on Stuvia, your review is my motivation. Success in your exam!!
DOYLE AND JODIE MCCUTCHEON (BCCAMPUS) 10th EDITION 2025
TEST BANK
Found this useful? Please leave a review on Stuvia, your review is my motivation. Success in your exam!!
, CHAPTER 8– DOCUMENTATION & LEGAL PRACTICE (25 NCLEX QS +
RATIONALES)
1. What is the most legally defensible method of documentation?
A. Verbal report
B. Abbreviated flow sheets
C. Objective, factual, timely charting
D. Charting by exception only
Answer: C
Rationale: Legal charting must be accurate, objective, and timely.
2. If a nurse makes an error in documentation, the correct action is to:
A. Erase it completely
B. Use white-out
C. Draw a single line through it and initial
D. Ask another nurse to rewrite it
Answer: C
Rationale: Corrections must be clearly marked and initialed to maintain legal integrity.
3. A patient refuses a treatment. What must the nurse do next?
A. Document the refusal and inform the provider
B. Re-attempt the treatment later
C. Persuade the patient
D. Leave it undocumented to avoid conflict
Answer: A
Rationale: Patient autonomy requires honoring refusal, with proper documentation and
reporting.
4. What does “charting by exception” mean?
A. Documenting only abnormal findings
B. Writing only every other shift
C. Documenting verbally
D. Skipping repetitive tasks
Answer: A
Rationale: Only deviations from normal are recorded.
Found this useful? Please leave a review on Stuvia, your review is my motivation. Success in your exam!!
