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

The correct method for correcting a handwritten medical record error is to draw a single line through the error (leaving it readable), write 'error' with the date, time, and initials above it, and then enter the correct information. White-out, obliteration, or removal of pages is never acceptable in medical documentation.

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

'Appears anxious' and 'uncooperative' are interpretive, subjective terms. Proper nursing documentation should use objective, factual, and measurable language. For example: 'Patient pacing in room, stating "I can't calm down," and refused to allow blood pressure assessment.'

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

The SBAR and Joint Commission standards require that verbal and telephone orders be written down, then read back verbatim to the prescriber for confirmation before implementation. The order is documented as 'T.O.' (telephone order) or 'V.O.' (verbal order) with the prescriber's name and the nurse's signature.

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

Late entries are permitted and are sometimes necessary. The note should be entered with the current date and time and labeled 'late entry for [original date and time].' Back-dating documentation is fraudulent. Late entries maintain the completeness of the health record.

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

This entry uses measurable, specific, and objective language: dimensions, tissue percentages, drainage type, and wound edge condition. This is the gold standard for wound documentation — it allows comparison over time and communicates clearly to all care team members.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #19 1