Questions) 2026 Exam All
Answers and Illustrations
Given
Which characteristic of effective documentation ensures the nurse
records only observations and not interpretations? - ANSWER
✔✔Factual
A nurse documents that a patient is "doing better today." Which element
of effective documentation did the nurse fail to follow? - ANSWER
✔✔Concise and Accurate (it is a vague, non-factual statement)
, What is the primary purpose of the patient record in clinical research? -
ANSWER ✔✔To provide data for studies to improve health care and
quality of care
A nurse forgets to log off a computer terminal after documenting. What
has occurred? - ANSWER ✔✔A breach of patient confidentiality
True or False: A patient has the right to revise their own medical record if
they disagree with a diagnosis. - ANSWER ✔✔False (Patients can
update or see records, but not revise/delete clinical entries)
Which element of documentation is most critical when the nurse is held
accountable for the timing of a medication? - ANSWER ✔✔Timing
(using the 24-hour military clock)
A nurse is receiving a verbal order during an emergency. What must the
nurse do to ensure accuracy? - ANSWER ✔✔Read back the order to
the physician
How should a nurse sign a verbal order in the medical record? -
ANSWER ✔✔Record the order, the physician's name, initials "VO",
followed by the nurse's name and title