Exam Bank
SAUNDERS NCLEX-PN DOCUMENTATION: 50 HIGH-YIELD PRACTICE
QUESTIONS WITH RATIONALES – 9TH EDITION TEST BANK
Author: Linda Anne Silvestri PhD RN ANEF FAAN
Documentation – Questions 1–50
1. What is the primary purpose of nursing documentation?
A. To share personal opinions
B. To provide a legal record of care ✅
C. To communicate only with physicians
D. To fill time during shifts
Rationale: Documentation serves as a legal record, communication tool, and basis for continuity
of care.
2. Which format is structured by problem, intervention, and evaluation?
A. Narrative charting
B. PIE charting ✅
C. Flow sheet
D. Electronic health record
Rationale: PIE (Problem-Intervention-Evaluation) organizes documentation around nursing care
problems.
3. Which statement is correct about electronic health records (EHR)?
A. They replace all forms of documentation
B. They improve accessibility, legibility, and safety ✅
C. They do not require documentation standards
D. They are optional
Rationale: EHRs enhance communication and patient safety but still require adherence to
standards.
4. Which of the following should NEVER be documented?
A. Patient’s vital signs
, Exam Bank
B. Personal opinions about the patient ✅
C. Pain assessment
D. Medication administered
Rationale: Documentation must be objective and factual; personal opinions are inappropriate.
5. A nurse documents “Patient appears anxious.” What is the issue?
A. Proper use of subjective data
B. Lacks objective measurement ✅
C. Correct and complete
D. Requires only verbal communication
Rationale: Documentation should include objective data or patient statements to support
observations.
6. Which abbreviation is acceptable in nursing documentation?
A. q.d.
B. per rectum ✅
C. U (for units)
D. cc
Rationale: Some abbreviations (like q.d., U, cc) are error-prone and discouraged; “per rectum”
is acceptable when standard.
7. A nurse documents late entries in a patient record. Which is correct?
A. Delete original entry
B. Add “late entry” with date/time ✅
C. Do not document
D. Rewrite entire record
Rationale: Late entries must be clearly identified to maintain accurate and legal documentation.
8. Which statement about incident reports is correct?
A. They are part of the patient’s medical record
B. They document deviations from care for quality improvement ✅
C. They replace nursing notes
D. They are optional
SAUNDERS NCLEX-PN DOCUMENTATION: 50 HIGH-YIELD PRACTICE
QUESTIONS WITH RATIONALES – 9TH EDITION TEST BANK
Author: Linda Anne Silvestri PhD RN ANEF FAAN
Documentation – Questions 1–50
1. What is the primary purpose of nursing documentation?
A. To share personal opinions
B. To provide a legal record of care ✅
C. To communicate only with physicians
D. To fill time during shifts
Rationale: Documentation serves as a legal record, communication tool, and basis for continuity
of care.
2. Which format is structured by problem, intervention, and evaluation?
A. Narrative charting
B. PIE charting ✅
C. Flow sheet
D. Electronic health record
Rationale: PIE (Problem-Intervention-Evaluation) organizes documentation around nursing care
problems.
3. Which statement is correct about electronic health records (EHR)?
A. They replace all forms of documentation
B. They improve accessibility, legibility, and safety ✅
C. They do not require documentation standards
D. They are optional
Rationale: EHRs enhance communication and patient safety but still require adherence to
standards.
4. Which of the following should NEVER be documented?
A. Patient’s vital signs
, Exam Bank
B. Personal opinions about the patient ✅
C. Pain assessment
D. Medication administered
Rationale: Documentation must be objective and factual; personal opinions are inappropriate.
5. A nurse documents “Patient appears anxious.” What is the issue?
A. Proper use of subjective data
B. Lacks objective measurement ✅
C. Correct and complete
D. Requires only verbal communication
Rationale: Documentation should include objective data or patient statements to support
observations.
6. Which abbreviation is acceptable in nursing documentation?
A. q.d.
B. per rectum ✅
C. U (for units)
D. cc
Rationale: Some abbreviations (like q.d., U, cc) are error-prone and discouraged; “per rectum”
is acceptable when standard.
7. A nurse documents late entries in a patient record. Which is correct?
A. Delete original entry
B. Add “late entry” with date/time ✅
C. Do not document
D. Rewrite entire record
Rationale: Late entries must be clearly identified to maintain accurate and legal documentation.
8. Which statement about incident reports is correct?
A. They are part of the patient’s medical record
B. They document deviations from care for quality improvement ✅
C. They replace nursing notes
D. They are optional
