Documentation and Reporting Practice Questions
20 free Documentation and Reporting practice questions for the NCLEX Exam, each with the correct answer and a detailed explanation. Open any question below, or take the full set as an interactive quiz.
Questions
20 questions
All Documentation and Reporting questions
- Q1. What is the safest course of action if a nurse discovers that a paper chart is missing an entry about a significant change in a patient’s status?
- Q2. Which documentation entry is most appropriate after giving a PRN pain medication?
- Q3. During shift-handoff report, what should the 'A' (Assessment) contain in the SBAR format?
- Q4. Why might documenting 'Patient is unstable at this time' be problematic?
- Q5. Which of the following best reflects a guideline for accurate charting?
- Q6. Under the “Charting by Exception” (CBE) method, which statement is true?
- Q7. What violation does a nurse likely commit by using a personal mobile device to photograph a patient’s wound for documentation without verifying patient consent?
- Q8. Which is the correct order for documentation when using the SOAPE format?
- Q9. What is an important safety practice when documenting in an electronic health record (EHR)?
- Q10. When giving a report about a patient who had a sudden drop in blood pressure, which information should be included?
- Q11. In the documentation “Patient refused morning lab work because she didn’t feel like it,” what part is problematic?
- Q12. The main purpose of nursing documentation includes all except:
- Q13. A nurse writes: “Patient is anxious about surgery; appropriate support provided.” What is a possible improvement to this note?
- Q14. Reporting an adverse event (e.g., patient fall) should include:
- Q15. What does the 'R' stand for in the focus charting (DAR) method?
- Q16. If a student nurse’s documentation contains misspellings and grammar errors, why is correctness important?
- Q17. During hand-off report, which patient should be discussed first?
- Q18. What should a nurse do if a colleague’s documentation has a large blank space between entries?
- Q19. Which statement about verbal orders is correct?
- Q20. If a nurse completes documentation for a procedure at 0400 though the procedure occurred at 0200, which principle of documentation is violated?