NCLEX-PN Test #19 1 — Questions and Answers
Question 1: A nurse makes an error in a handwritten nursing note and needs to correct it. Which action reflects the correct documentation procedure?
- Use correction fluid (white-out) to cover the error and rewrite
- Scribble heavily over the error so it is illegible
- Draw a single line through the error, write 'error,' and add initials and date (Correct answer)
- Tear out the page and rewrite the note on a fresh sheet
Correct answer: Draw a single line through the error, write 'error,' and add initials and date
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?
- Objective documentation
- Subjective and interpretive documentation (Correct answer)
- Appropriate use of medical terminology
- Legally sound documentation
Correct answer: Subjective and interpretive documentation
'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?
- Write the order directly in the chart and sign it
- Write the order, read it back to the physician for verification, and note 'T.O. read back' (Correct answer)
- Wait until the physician comes to the unit to sign the order before acting on it
- Ask the charge nurse to take all verbal orders
Correct answer: Write the order, read it back to the physician for verification, and note 'T.O. read back'
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?
- Add the note between existing entries and use the current date and time
- Insert the note in chronological order by back-dating it to the original time
- Write a new entry with the current date and time, noting it as a late entry for the original time (Correct answer)
- Leave it out — late entries are not permitted in medical documentation
Correct answer: Write a new entry with the current date and time, noting it as a late entry for the original time
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?
- Subjective documentation
- Objective, factual, and specific documentation (Correct answer)
- Interpretive documentation
- Incomplete documentation
Correct answer: Objective, factual, and specific documentation
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.
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?
- Delete the entry from the electronic record
- Edit the other nurse's entry to correct the error
- Notify the nurse who made the entry and the charge nurse; document a clarifying addendum if appropriate (Correct answer)
- Leave the entry as is to avoid conflict with a colleague
Correct answer: Notify the nurse who made the entry and the charge nurse; document a clarifying addendum if appropriate
Only the author of a medical record entry may correct or amend it. The appropriate response is to bring the discrepancy to the attention of the nurse who made the entry and the charge nurse. An addendum may be added by the appropriate provider. Editing or deleting another clinician's entry is never permissible.
NCLEX-PN Test #19 1
A nurse makes an error in a handwritten nursing note and needs to correct it.
Which action reflects the correct documentation procedure?