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
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
