RELIAS DOCUMENTATION AND LEGAL
ISSUES IN NURSING EXAM QUESTION
AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A
INSTANT DOWNLOAD PDF
1. What is the best way to correct an error in a paper nursing record?
A. Erase it completely
B. Use correction fluid
C. Draw a single line through the error, write the correction, and
initial it
D. Ignore it
C. Draw a single line through the error, write the correction, and
initial it
This method maintains the integrity of the original entry and
complies with legal documentation standards.
2. Which of the following is considered confidential patient
information?
A. Patient room number
B. Patient diagnosis
C. Nurse’s schedule
D. Cafeteria menu
B. Patient diagnosis
Patient diagnosis is protected health information under HIPAA
and must be kept confidential.
,3. HIPAA primarily protects:
A. Patient billing information
B. Employee performance records
C. Patient health information
D. Staff schedules
C. Patient health information
HIPAA ensures privacy and security of patient medical
information.
4. Which type of consent is required before performing a surgical
procedure?
A. Verbal consent
B. Implied consent
C. Written informed consent
D. No consent needed
C. Written informed consent
Written informed consent legally documents that the patient
understands the procedure, risks, and alternatives.
5. What is the primary purpose of incident reports in nursing?
A. Punish staff
B. Track errors for legal reasons
C. Improve patient safety and prevent recurrence
D. Document routine care
C. Improve patient safety and prevent recurrence
Incident reports help identify patterns and prevent future
adverse events.
6. Which of the following actions can be considered professional
negligence?
, A. Administering medication as prescribed
B. Failing to monitor a patient appropriately
C. Documenting care promptly
D. Reporting a patient fall
B. Failing to monitor a patient appropriately
Negligence occurs when the nurse fails to provide the standard
of care, leading to patient harm.
7. In legal terms, which of the following describes assault?
A. Touching a patient without consent
B. Threatening a patient with harm
C. Performing routine care
D. Administering prescribed medication
B. Threatening a patient with harm
Assault is the act of creating fear of harmful or offensive contact.
8. Battery is defined as:
A. Threatening a patient
B. Physical contact without consent
C. Failing to document care
D. Ignoring physician orders
B. Physical contact without consent
Battery involves unauthorized physical contact, even if no injury
occurs.
9. Which of the following is a patient’s right under the Patient Bill of
Rights?
A. Right to receive unsafe care
B. Right to privacy and confidentiality
C. Right to refuse medical documentation
, D. Right to ignore treatment plans
B. Right to privacy and confidentiality
Patients are legally entitled to privacy in all aspects of care.
10. Which is the most legally sound way to document patient
education?
A. Write “taught patient” in notes
B. Include specific content, patient response, and understanding
C. Use abbreviations without explanation
D. Omit documentation if teaching was brief
B. Include specific content, patient response, and understanding
Detailed documentation protects the nurse legally and ensures
quality care.
11. When is verbal consent acceptable?
A. For major surgery
B. For routine care, such as taking vital signs
C. For experimental treatment
D. For invasive procedures
B. For routine care, such as taking vital signs
Verbal consent is sufficient for non-invasive, low-risk procedures.
12. Which documentation method records patient care in
chronological order?
A. Narrative charting
B. Problem-oriented charting
C. PIE charting
D. Flow sheets
A. Narrative charting
ISSUES IN NURSING EXAM QUESTION
AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A
INSTANT DOWNLOAD PDF
1. What is the best way to correct an error in a paper nursing record?
A. Erase it completely
B. Use correction fluid
C. Draw a single line through the error, write the correction, and
initial it
D. Ignore it
C. Draw a single line through the error, write the correction, and
initial it
This method maintains the integrity of the original entry and
complies with legal documentation standards.
2. Which of the following is considered confidential patient
information?
A. Patient room number
B. Patient diagnosis
C. Nurse’s schedule
D. Cafeteria menu
B. Patient diagnosis
Patient diagnosis is protected health information under HIPAA
and must be kept confidential.
,3. HIPAA primarily protects:
A. Patient billing information
B. Employee performance records
C. Patient health information
D. Staff schedules
C. Patient health information
HIPAA ensures privacy and security of patient medical
information.
4. Which type of consent is required before performing a surgical
procedure?
A. Verbal consent
B. Implied consent
C. Written informed consent
D. No consent needed
C. Written informed consent
Written informed consent legally documents that the patient
understands the procedure, risks, and alternatives.
5. What is the primary purpose of incident reports in nursing?
A. Punish staff
B. Track errors for legal reasons
C. Improve patient safety and prevent recurrence
D. Document routine care
C. Improve patient safety and prevent recurrence
Incident reports help identify patterns and prevent future
adverse events.
6. Which of the following actions can be considered professional
negligence?
, A. Administering medication as prescribed
B. Failing to monitor a patient appropriately
C. Documenting care promptly
D. Reporting a patient fall
B. Failing to monitor a patient appropriately
Negligence occurs when the nurse fails to provide the standard
of care, leading to patient harm.
7. In legal terms, which of the following describes assault?
A. Touching a patient without consent
B. Threatening a patient with harm
C. Performing routine care
D. Administering prescribed medication
B. Threatening a patient with harm
Assault is the act of creating fear of harmful or offensive contact.
8. Battery is defined as:
A. Threatening a patient
B. Physical contact without consent
C. Failing to document care
D. Ignoring physician orders
B. Physical contact without consent
Battery involves unauthorized physical contact, even if no injury
occurs.
9. Which of the following is a patient’s right under the Patient Bill of
Rights?
A. Right to receive unsafe care
B. Right to privacy and confidentiality
C. Right to refuse medical documentation
, D. Right to ignore treatment plans
B. Right to privacy and confidentiality
Patients are legally entitled to privacy in all aspects of care.
10. Which is the most legally sound way to document patient
education?
A. Write “taught patient” in notes
B. Include specific content, patient response, and understanding
C. Use abbreviations without explanation
D. Omit documentation if teaching was brief
B. Include specific content, patient response, and understanding
Detailed documentation protects the nurse legally and ensures
quality care.
11. When is verbal consent acceptable?
A. For major surgery
B. For routine care, such as taking vital signs
C. For experimental treatment
D. For invasive procedures
B. For routine care, such as taking vital signs
Verbal consent is sufficient for non-invasive, low-risk procedures.
12. Which documentation method records patient care in
chronological order?
A. Narrative charting
B. Problem-oriented charting
C. PIE charting
D. Flow sheets
A. Narrative charting
