Week 3 NDOC ACTUAL EXAM
2026/2027 | NDOC Nevada Department of
Corrections | Verified Q&A | Pass
Guaranteed - A+ Graded
Section A: Legal & Ethical Principles of Nursing Documentation
Q1: A nurse realizes 3 hours after her shift ended that she forgot to document a routine assessment
performed at 1400. The facility uses an Electronic Health Record (EHR). Which action is legally
compliant?
A. Document the assessment now, but change the time in the system to 1400 to reflect when it actually
occurred.
B. Wait until the next shift to document the assessment so it does not look like overtime was worked.
C. Make a "late entry" notation, document the current time, and note in the text that the assessment
was performed at 1400. [CORRECT]
D. Call the charge nurse on the next shift and ask them to document it for the previous shift.
Correct Answer: C
Rationale: Backdating an entry (Option A) is falsification of medical records. Documentation should
reflect the actual time of entry, with a notation of the time the care was provided (late entry). Option B
delays communication of patient status. Option D involves another person documenting care they did
not witness or perform, which is a falsification.
Q2: While reviewing a chart, a nurse discovers a documentation error where "Right leg amputated" was
written instead of "Left leg amputated." What is the correct method to correct this error in a paper
chart?
A. Use white-out to cover the error and write the correct information.
,B. Scribble out the error so it cannot be read, then write the correct information.
C. Draw a single line through the error, write "error" above it, initial, date, and write the correct
information. [CORRECT]
D. Remove the page from the chart and rewrite the entire page.
Correct Answer: C
Rationale: Legal standards require that original entries remain legible to prevent accusations of
tampering or fraud. White-out (A) and removing pages (D) are strictly prohibited as they destroy the
audit trail. Scribbling out (B) obscures the original entry. The single-line method preserves the integrity
of the record while correcting the information.
Q3: [2026/2027 Update] A nurse utilizes an Ambient AI Scribe tool to transcribe a patient encounter.
Which statement reflects the nurse's accountability regarding the AI-generated note?
A. The AI vendor is responsible for the accuracy of the note since the software generated it.
B. The nurse must review the note for accuracy, edit as necessary, and authenticate (sign) the entry as if
they wrote it themselves. [CORRECT]
C. The note must be flagged as "AI Generated" and does not require the nurse's signature.
D. The nurse is only responsible for the subjective data; the AI is responsible for the objective data.
Correct Answer: B
Rationale: Under 2026 nursing board guidelines regarding AI, the licensed professional remains fully
accountable for the content of the medical record. The nurse must verify the accuracy of the
transcription and sign/authenticate the entry. The license holder cannot delegate accountability to a
software vendor.
Q4: A patient refuses to take their prescribed antihypertensive medication. Which documentation entry
is legally sufficient?
A. "Patient refused medication."
, B. "Patient stated, 'I don't want that pill,' and refused to take it. Patient education provided regarding
risks of uncontrolled hypertension; patient verbalized understanding but continued to refuse."
[CORRECT]
C. "Patient is non-compliant with medication regimen."
D. "Medication held due to patient stubbornness."
Correct Answer: B
Rationale: Documentation must be objective and include the patient's specific words (subjective data),
the education provided to ensure an informed refusal, and the patient's response. Option A is
insufficient as it lacks context. Option C uses a judgmental label ("non-compliant") rather than objective
facts. Option D is subjective and unprofessional language.
Q5: [Refusal Documentation] A patient threatens to sign out Against Medical Advice (AMA). The
physician has been notified. Which documentation is essential to mitigate liability?
A. "Patient is leaving AMA. Doctor notified."
B. "Patient informed of risks of leaving, including possibility of death or further injury. Patient verbalized
understanding of risks and signed AMA form. Vital signs stable prior to departure." [CORRECT]
C. "Patient signed AMA form."
D. "Patient is making a poor decision to leave; nurse disagree
s."
Correct Answer: B
Rationale: To mitigate liability for abandonment or lack of informed consent, the record must prove the
patient was informed of the specific risks of leaving. The nurse must document the education provided,
the patient's understanding, and the signature on the AMA form.
Q6: [2026/2027 Update] A nurse documents a telehealth encounter. Which specific element is legally
required in addition to standard documentation?
A. The IP address of the patient's device.
2026/2027 | NDOC Nevada Department of
Corrections | Verified Q&A | Pass
Guaranteed - A+ Graded
Section A: Legal & Ethical Principles of Nursing Documentation
Q1: A nurse realizes 3 hours after her shift ended that she forgot to document a routine assessment
performed at 1400. The facility uses an Electronic Health Record (EHR). Which action is legally
compliant?
A. Document the assessment now, but change the time in the system to 1400 to reflect when it actually
occurred.
B. Wait until the next shift to document the assessment so it does not look like overtime was worked.
C. Make a "late entry" notation, document the current time, and note in the text that the assessment
was performed at 1400. [CORRECT]
D. Call the charge nurse on the next shift and ask them to document it for the previous shift.
Correct Answer: C
Rationale: Backdating an entry (Option A) is falsification of medical records. Documentation should
reflect the actual time of entry, with a notation of the time the care was provided (late entry). Option B
delays communication of patient status. Option D involves another person documenting care they did
not witness or perform, which is a falsification.
Q2: While reviewing a chart, a nurse discovers a documentation error where "Right leg amputated" was
written instead of "Left leg amputated." What is the correct method to correct this error in a paper
chart?
A. Use white-out to cover the error and write the correct information.
,B. Scribble out the error so it cannot be read, then write the correct information.
C. Draw a single line through the error, write "error" above it, initial, date, and write the correct
information. [CORRECT]
D. Remove the page from the chart and rewrite the entire page.
Correct Answer: C
Rationale: Legal standards require that original entries remain legible to prevent accusations of
tampering or fraud. White-out (A) and removing pages (D) are strictly prohibited as they destroy the
audit trail. Scribbling out (B) obscures the original entry. The single-line method preserves the integrity
of the record while correcting the information.
Q3: [2026/2027 Update] A nurse utilizes an Ambient AI Scribe tool to transcribe a patient encounter.
Which statement reflects the nurse's accountability regarding the AI-generated note?
A. The AI vendor is responsible for the accuracy of the note since the software generated it.
B. The nurse must review the note for accuracy, edit as necessary, and authenticate (sign) the entry as if
they wrote it themselves. [CORRECT]
C. The note must be flagged as "AI Generated" and does not require the nurse's signature.
D. The nurse is only responsible for the subjective data; the AI is responsible for the objective data.
Correct Answer: B
Rationale: Under 2026 nursing board guidelines regarding AI, the licensed professional remains fully
accountable for the content of the medical record. The nurse must verify the accuracy of the
transcription and sign/authenticate the entry. The license holder cannot delegate accountability to a
software vendor.
Q4: A patient refuses to take their prescribed antihypertensive medication. Which documentation entry
is legally sufficient?
A. "Patient refused medication."
, B. "Patient stated, 'I don't want that pill,' and refused to take it. Patient education provided regarding
risks of uncontrolled hypertension; patient verbalized understanding but continued to refuse."
[CORRECT]
C. "Patient is non-compliant with medication regimen."
D. "Medication held due to patient stubbornness."
Correct Answer: B
Rationale: Documentation must be objective and include the patient's specific words (subjective data),
the education provided to ensure an informed refusal, and the patient's response. Option A is
insufficient as it lacks context. Option C uses a judgmental label ("non-compliant") rather than objective
facts. Option D is subjective and unprofessional language.
Q5: [Refusal Documentation] A patient threatens to sign out Against Medical Advice (AMA). The
physician has been notified. Which documentation is essential to mitigate liability?
A. "Patient is leaving AMA. Doctor notified."
B. "Patient informed of risks of leaving, including possibility of death or further injury. Patient verbalized
understanding of risks and signed AMA form. Vital signs stable prior to departure." [CORRECT]
C. "Patient signed AMA form."
D. "Patient is making a poor decision to leave; nurse disagree
s."
Correct Answer: B
Rationale: To mitigate liability for abandonment or lack of informed consent, the record must prove the
patient was informed of the specific risks of leaving. The nurse must document the education provided,
the patient's understanding, and the signature on the AMA form.
Q6: [2026/2027 Update] A nurse documents a telehealth encounter. Which specific element is legally
required in addition to standard documentation?
A. The IP address of the patient's device.
