NCLEX-PN Test #19 1

Question 1

A nurse makes an error in a handwritten nursing note and needs to correct it. Which action reflects the correct documentation procedure?

Accepted Answer

Draw a single line through the error, write 'error,' and add initials and date

Answer

Use correction fluid (white-out) to cover the error and rewrite

Answer

Scribble heavily over the error so it is illegible

Answer

Tear out the page and rewrite the note on a fresh sheet

Question 2

A nurse documents 'Patient appears anxious and uncooperative' in the medical record. Which documentation practice is this an example of?

Accepted Answer

Subjective and interpretive documentation

Answer

Objective documentation

Answer

Appropriate use of medical terminology

Answer

Legally sound documentation

Question 3

A nurse gives a verbal telephone order from a physician. What is the correct procedure for handling this order?

Accepted Answer

Write the order, read it back to the physician for verification, and note 'T.O. read back'

Answer

Write the order directly in the chart and sign it

Answer

Wait until the physician comes to the unit to sign the order before acting on it

Answer

Ask the charge nurse to take all verbal orders

Question 4

A nurse realizes that a late entry must be added to the patient's chart for an assessment performed 2 hours ago. What is the correct approach?

Accepted Answer

Write a new entry with the current date and time, noting it as a late entry for the original time

Answer

Add the note between existing entries and use the current date and time

Answer

Insert the note in chronological order by back-dating it to the original time

Answer

Leave it out — late entries are not permitted in medical documentation

Question 5

A nurse completes a wound assessment and documents: 'Wound on right lower leg measures 2.5 cm x 1.8 cm, wound bed 80% granulation tissue, 20% yellow slough, scant serosanguineous drainage, edges approximated.' This documentation style best reflects which principle?

Accepted Answer

Objective, factual, and specific documentation

Answer

Subjective documentation

Answer

Interpretive documentation

Answer

Incomplete documentation

Question 6

A nurse is reviewing a patient's electronic health record and notes that another nurse's entry contains inaccurate information. What is the most appropriate action?

Accepted Answer

Notify the nurse who made the entry and the charge nurse; document a clarifying addendum if appropriate

Answer

Delete the entry from the electronic record

Answer

Edit the other nurse's entry to correct the error

Answer

Leave the entry as is to avoid conflict with a colleague