Next Communication and Documentation 2 — Questions and Answers
Question 1: A nurse is documenting a patient's response to pain medication. Which entry best reflects objective documentation?
- Patient states pain decreased from 8/10 to 3/10 after medication (Correct answer)
- Patient seems more comfortable after receiving analgesic
- Patient's pain appears to be improving significantly
- Patient tolerated medication well with no apparent distress
Correct answer: Patient states pain decreased from 8/10 to 3/10 after medication
Objective documentation quotes the patient's own words and uses measurable data such as numeric pain scales.
Question 2: Which situation requires an incident report in addition to a nursing note?
- A patient falls out of bed during the shift (Correct answer)
- A patient refuses a scheduled medication
- A patient requests additional blankets
- A patient asks to speak with the physician
Correct answer: A patient falls out of bed during the shift
Patient falls are unexpected events that pose safety risks and must be documented on an incident report separate from the medical record.
Question 3: When using the SBAR communication tool, what does the 'R' stand for?
- Recommendation (Correct answer)
- Response
- Rationale
- Review
Correct answer: Recommendation
In SBAR (Situation, Background, Assessment, Recommendation), 'R' stands for Recommendation — the nurse's suggested action.
Question 4: A nurse discovers an error in a paper medical record. What is the correct action?
- Draw a single line through the error, write 'error,' initial, and date it (Correct answer)
- Use correction fluid to cover the mistake and write the correct information
- Erase the error completely and rewrite the correct information
- Tear out the page and rewrite the entire entry
Correct answer: Draw a single line through the error, write 'error,' initial, and date it
The standard procedure for correcting paper chart errors is a single line through the error with 'error,' initials, and the date to maintain record integrity.
Question 5: A nurse is preparing to give a telephone order from a physician. Which step is essential to ensure safety?
- Read back the complete order to the physician for verification (Correct answer)
- Write the order down and implement it immediately
- Ask another nurse to listen to the call
- Document the order after the shift ends
Correct answer: Read back the complete order to the physician for verification
Read-back of telephone orders is a critical safety step that allows the prescriber to confirm accuracy before implementation.
Question 6: Which of the following is the most appropriate way to communicate a critical lab value to the physician?
- Call the physician directly and document the time, name of person notified, and physician's response (Correct answer)
- Leave a note in the chart and wait for the physician to review it
- Send a secure message and continue other tasks
- Report the value at the next scheduled team meeting
Correct answer: Call the physician directly and document the time, name of person notified, and physician's response
Critical values require immediate verbal notification followed by thorough documentation of the communication loop.
Question 7: Under HIPAA, a nurse may share a patient's protected health information (PHI) without written authorization for which purpose?
- Treatment, payment, and healthcare operations (Correct answer)
- Marketing a new hospital service
- Research that does not involve IRB approval
- Sharing with the patient's employer upon request
Correct answer: Treatment, payment, and healthcare operations
HIPAA's Privacy Rule permits disclosure of PHI without patient authorization for treatment, payment, and healthcare operations.
Next Communication and Documentation 2
A nurse is documenting a patient's response to pain medication.
Which entry best reflects objective documentation?