NURS 101L | Fundamentals of Nursing Skills Lab | Documentation &
Charting Skills 2026 |WCU
1. A nurse is documenting a patient’s response to pain medication. Which of the
following entries is the most objective and accurate?
A. The patient seems to feel better after the dose of morphine.
B. Morphine 2mg IV administered; patient reports pain decreased from 8/10 to 3/10 within 30 minutes.
C. Patient is sleeping peacefully and appears to have no more pain.
D. The medication was effective as the patient is no longer complaining.
Answer: B
Rationale: Objective documentation must include specific, measurable data such as the
scale rating and time frame rather than subjective interpretations like ‘seems’ or ‘appears’.
2. While documenting on a paper-based record, a nurse makes an error. What is
the legally appropriate way to correct this?
A. Use white-out or correction fluid to cover the error completely.
B. Draw a single line through the error, write ‘error’ or ‘mistaken entry’, and initial it.
C. Scribble over the entry until it is completely illegible.
D. Erase the error with a high-quality eraser and write the correct information over it.
Answer: B
Rationale: Legal standards require that the original entry remains visible; a single line
with initials and the word ‘error’ or ‘mistaken entry’ preserves the integrity of the medical
record.
,3. The nurse is using the SBAR communication tool. Which information belongs
in the ‘B’ (Background) section?
A. The patient’s admitting diagnosis, medical history, and allergies.
B. A request for a specific change in the patient’s treatment plan.
C. The reason for the current call or the patient’s acute change in status.
D. The patient’s current vital signs and mental status.
Answer: A
Rationale: ‘Background’ includes the context of the patient’s admission, past medical
history, and relevant clinical history leading up to the current situation.
4. A nursing student is looking at a patient’s electronic health record (EHR) who
is not assigned to them but is a neighbor. This action is a violation of:
A. The Joint Commission safety standards.
B. HIPAA (Health Insurance Portability and Accountability Act).
C. The Patient’s Bill of Rights.
D. The Affordable Care Act.
Answer: B
Rationale: Accessing records of patients not under your direct care for personal reasons is
a direct violation of HIPAA privacy regulations.
5. In Focus Charting (DAR), what does the ‘A’ represent?
A. Action: The nursing interventions performed.
B. Assessment: The subjective and objective data collected.
C. Analysis: The nurse’s interpretation of the patient’s condition.
D. Admission: The process of checking the patient into the unit.
Answer: A
Rationale: In the DAR (Data, Action, Response) format, ‘A’ stands for the specific nursing
interventions or actions taken in response to the ‘D’ (Data).
, 6. A physician gives a verbal order for a medication during a stable situation.
What is the nurse’s priority action?
A. Read the order back to the physician to verify accuracy.
B. Write the order down and have the physician sign it before administration.
C. Administer the medication immediately to avoid delay.
D. Ask another nurse to witness the verbal order.
Answer: A
Rationale: For verbal or telephone orders, the nurse must ‘Read Back’ the order to ensure
accuracy and prevent medication errors.
7. Which of the following abbreviations is on the Joint Commission’s ‘Do Not
Use’ list?
A. NPO
B. q.d. (every day)
C. PRN
D. IV
Answer: B
Rationale: ‘q.d.’ can be mistaken for ‘q.i.d.’ (four times a day). The Joint Commission
requires writing out ‘daily’ or ‘every day’.
8. Documentation by Exception (CBE) assumes that:
A. All standards of care are met unless otherwise documented.
B. The nurse must chart every single action taken throughout the shift.
C. Subjective data is more important than objective data.
D. Only critical incidents require any form of charting.
Answer: A
Rationale: CBE is a shorthand method that assumes all routine standards are met and only
significant findings or exceptions to the norm are documented.
Charting Skills 2026 |WCU
1. A nurse is documenting a patient’s response to pain medication. Which of the
following entries is the most objective and accurate?
A. The patient seems to feel better after the dose of morphine.
B. Morphine 2mg IV administered; patient reports pain decreased from 8/10 to 3/10 within 30 minutes.
C. Patient is sleeping peacefully and appears to have no more pain.
D. The medication was effective as the patient is no longer complaining.
Answer: B
Rationale: Objective documentation must include specific, measurable data such as the
scale rating and time frame rather than subjective interpretations like ‘seems’ or ‘appears’.
2. While documenting on a paper-based record, a nurse makes an error. What is
the legally appropriate way to correct this?
A. Use white-out or correction fluid to cover the error completely.
B. Draw a single line through the error, write ‘error’ or ‘mistaken entry’, and initial it.
C. Scribble over the entry until it is completely illegible.
D. Erase the error with a high-quality eraser and write the correct information over it.
Answer: B
Rationale: Legal standards require that the original entry remains visible; a single line
with initials and the word ‘error’ or ‘mistaken entry’ preserves the integrity of the medical
record.
,3. The nurse is using the SBAR communication tool. Which information belongs
in the ‘B’ (Background) section?
A. The patient’s admitting diagnosis, medical history, and allergies.
B. A request for a specific change in the patient’s treatment plan.
C. The reason for the current call or the patient’s acute change in status.
D. The patient’s current vital signs and mental status.
Answer: A
Rationale: ‘Background’ includes the context of the patient’s admission, past medical
history, and relevant clinical history leading up to the current situation.
4. A nursing student is looking at a patient’s electronic health record (EHR) who
is not assigned to them but is a neighbor. This action is a violation of:
A. The Joint Commission safety standards.
B. HIPAA (Health Insurance Portability and Accountability Act).
C. The Patient’s Bill of Rights.
D. The Affordable Care Act.
Answer: B
Rationale: Accessing records of patients not under your direct care for personal reasons is
a direct violation of HIPAA privacy regulations.
5. In Focus Charting (DAR), what does the ‘A’ represent?
A. Action: The nursing interventions performed.
B. Assessment: The subjective and objective data collected.
C. Analysis: The nurse’s interpretation of the patient’s condition.
D. Admission: The process of checking the patient into the unit.
Answer: A
Rationale: In the DAR (Data, Action, Response) format, ‘A’ stands for the specific nursing
interventions or actions taken in response to the ‘D’ (Data).
, 6. A physician gives a verbal order for a medication during a stable situation.
What is the nurse’s priority action?
A. Read the order back to the physician to verify accuracy.
B. Write the order down and have the physician sign it before administration.
C. Administer the medication immediately to avoid delay.
D. Ask another nurse to witness the verbal order.
Answer: A
Rationale: For verbal or telephone orders, the nurse must ‘Read Back’ the order to ensure
accuracy and prevent medication errors.
7. Which of the following abbreviations is on the Joint Commission’s ‘Do Not
Use’ list?
A. NPO
B. q.d. (every day)
C. PRN
D. IV
Answer: B
Rationale: ‘q.d.’ can be mistaken for ‘q.i.d.’ (four times a day). The Joint Commission
requires writing out ‘daily’ or ‘every day’.
8. Documentation by Exception (CBE) assumes that:
A. All standards of care are met unless otherwise documented.
B. The nurse must chart every single action taken throughout the shift.
C. Subjective data is more important than objective data.
D. Only critical incidents require any form of charting.
Answer: A
Rationale: CBE is a shorthand method that assumes all routine standards are met and only
significant findings or exceptions to the norm are documented.
