NLE Fundamentals of Nursing & the Nursing Process Reviewer 2026

Answer: B. Draw a single line through the error, write 'error' with initials and date, then enter the correct information.

Step 1: Understand why this matters — the patient chart is a legal document. Any alteration that hides what was originally written can be considered falsification. Step 2: The correct method is to draw ONE single line through the error so the original entry remains legible. Step 3: Write 'error' (or per facility policy), your initials, and the date next to the line. Step 4: Write the correct entry. Step 5: Options A and C are wrong because using white-out or erasing destroys evidence of what was originally written, which is illegal. Option D is wrong because tearing out pages constitutes destruction of a legal record and is never acceptable.

Answer: C. What the patient states in his or her own words.

Step 1: Recall the SOAPIE acronym: Subjective, Objective, Assessment, Plan, Implementation, Evaluation. Step 2: 'S' stands for Subjective — this is information that comes directly from the patient's perspective and cannot be independently measured. Step 3: It is always documented in quotes, e.g., 'Nahihirapan akong huminga' or 'I feel short of breath.' Step 4: Option A describes the 'A' (Assessment) component. Option B describes the 'O' (Objective) component — vital signs and lab values are measurable, not subjective. Option D describes the 'I' (Implementation) component. Step 5: Remember: Subjective = the patient says it; Objective = the nurse measures or observes it.

Answer: B. SBAR

Step 1: Identify what each tool is used for. SBAR stands for Situation, Background, Assessment, Recommendation — it is a standardized verbal communication framework. Step 2: SBAR was designed specifically to improve nurse-to-physician communication and reduce errors during critical updates. Step 3: SOAPIE and DAR and PIE are documentation (charting) formats — they are written tools, not verbal reporting tools. Step 4: In the NLE context, whenever you see 'nurse reporting to physician' or 'telephone communication about a patient change,' the answer is almost always SBAR. Step 5: Key mnemonic — SBAR = calling the doctor; SOAPIE = writing in the chart.

Answer: A. If it was not documented, it was not done.

Step 1: The gold standard principle is: 'If it was not documented, it was not done.' This applies in legal proceedings, audits, and quality reviews. Step 2: Option B is wrong — documentation must be done in a timely manner, as soon as possible after care, not all at the end of the shift. Block or retrospective charting is poor practice. Step 3: Option C is wrong — nurses must only chart care they personally performed or directly observed; charting for another provider is unethical and illegal. Step 4: Option D is wrong — only facility-approved abbreviations are acceptable. A textbook abbreviation may not be recognized or may have different meanings in that institution. Step 5: This principle underlies all nursing accountability under RA 9173 and the Code of Ethics.

Answer: C. Assess and stabilize the patient, then notify the physician.

Step 1: Apply Maslow's hierarchy — physiologic safety and immediate patient welfare always come first. Step 2: After any adverse event, the nurse's first action is ALWAYS to assess the patient for injury and stabilize their condition (ABCs, vital signs, pain, visible injuries). Step 3: After the patient is stabilized, notify the physician and document the patient's condition and the care provided in the chart. Step 4: The incident report comes after patient care is addressed — it is a quality-improvement and risk-management tool, not a clinical priority. Step 5: Option D is wrong — you never leave or delay attending to the patient to inform supervisors first. Supervisors and the incident report can wait; the patient cannot.

Answer: B. Read the order back to Dr. Reyes to confirm accuracy.

Step 1: The correct process for telephone orders is: Write it down → Read it back → Receive confirmation. This is called the 'read-back/repeat-back' technique. Step 2: Reading the order back ensures accuracy and prevents medication errors caused by similar-sounding drug names (e.g., 'Losartan' vs. 'Lozapin'). Step 3: Option A is wrong — you must verify first before carrying out a telephone order. Step 4: Option C is wrong — any licensed nurse may receive a telephone order; it does not have to be the charge nurse. Step 5: Option D is wrong — verbal and telephone orders are accepted in clinical practice with the read-back safety check; the physician countersigns within the facility's required timeframe. Document as 'TO: Dr. Reyes / Nurse Liza' with date and time.

Answer: C. RA 10173 — Data Privacy Act of 2012

Step 1: RA 10173, or the Data Privacy Act of 2012, is the Philippine law that protects personal and sensitive personal information, including health records. Step 2: It governs how information is collected, stored, processed, and disclosed — violations carry civil, criminal, and administrative penalties. Step 3: RA 9173 (Philippine Nursing Act of 2002) governs the nursing profession, licensing, scope of practice, and accountability — it reinforces record-keeping obligations but does NOT specifically govern data privacy. Step 4: RA 7160 is the Local Government Code (irrelevant here). RA 8981 deals with PRC operations. Step 5: For NLE purposes: Data Privacy = RA 10173; Nursing Practice Law = RA 9173. Know both numbers.

Answer: C. Log off the system when leaving the workstation unattended.

Step 1: EMR security requires that each entry be traceable to the correct nurse — this is done through individual login credentials. Step 2: Logging off when leaving the workstation prevents unauthorized access to patient records and protects both the patient's privacy and the nurse's professional accountability. Step 3: Option A is wrong — sharing passwords is prohibited; each nurse is personally accountable for entries made under their login. Step 4: Option B describes 'copy-paste cloning' — this propagates outdated or inaccurate information and is considered a documentation error. The current patient's condition must be freshly assessed and documented. Step 5: Option D is wrong — nurses must still actively document interventions, assessments, and patient responses; the EMR does not document automatically. The same legal and ethical standards of paper charting apply to EMR.

Answer: B. The patient's condition and the nursing care provided after the event.

Step 1: Understand that the incident report and the patient's chart are TWO SEPARATE documents serving different purposes. Step 2: In the patient's chart, document factually: the patient's condition at the time of the event, the assessment findings, and the nursing care and physician notifications that followed. Step 3: The chart does NOT mention the incident report — not its existence, not its number, not who filled it out. This is a critical legal distinction. Step 4: The incident report goes to risk management and quality improvement — it is an internal administrative tool. If it is referenced in the chart, it becomes discoverable in litigation, which is why they are kept completely separate. Step 5: Options A, C, and D all describe content that must NEVER appear in the patient's chart in relation to an incident report.

Answer: B. Only when there are significant findings or deviations from established norms.

Step 1: Charting by Exception (CBE) is based on the assumption that if nothing is charted, the patient's assessment findings were within normal/expected limits as defined by the facility's standards. Step 2: This reduces repetitive documentation for routine, normal findings. Step 3: A narrative or focused note is written ONLY when findings deviate from normal — for example, a new rash, a drop in SpO2, a refusal of medications, or unexpected vital sign changes. Step 4: Option A is wrong — CBE is specifically designed to avoid writing notes for every routine assessment. Option C is wrong — CBE does not require notes at every shift boundary when findings are normal. Option D is partially right but incomplete — deviations from normal include more than just patient complaints (e.g., abnormal objective findings). Step 5: CBE reduces documentation burden but requires well-defined institutional norms and checklists to be safe and legally sound.

Answer: B. From inner to outer canthus, using a clean section of the washcloth for each eye

Step 1 – Understand the principle: Eyes are washed from the inner canthus (near the nose) to the outer canthus (near the ear). This direction moves debris and microorganisms away from the lacrimal duct, preventing infection and blockage. Step 2 – Why a clean section each time: The eye is a sterile/near-sterile structure. Using a different section of the washcloth (or a new cloth) for each eye prevents cross-contamination between eyes, which is especially important if one eye is infected. Step 3 – Eliminate wrong options: Outer-to-inner direction pushes microorganisms toward the lacrimal duct — this is incorrect. Using the same section for both eyes risks transferring organisms from one eye to the other. Step 4 – Key takeaway: Always apply the clean-to-dirty principle during hygiene; eyes are washed first, before the rest of the face.

Answer: B. From urethra to anus (front to back)

Step 1 – The rationale: The urethra and vaginal opening are located anteriorly (front), while the anus is posterior (back). Cleaning front to back moves microorganisms (particularly fecal flora like E. coli) away from the urethra, preventing urinary tract infections (UTIs). Step 2 – Why back-to-front is wrong: Cleaning from the anus toward the urethra introduces fecal bacteria into the urinary tract — the most common cause of catheter-associated UTIs and community-acquired UTIs in women. Step 3 – Circular motion is incorrect: This technique does not consistently move contaminants away from the urethral meatus. Step 4 – Apply this principle to catheter care as well: Always clean the catheter using the same front-to-back direction. Step 5 – Key takeaway: Front to back = clean to dirty in perineal care.