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Question 1

A nurse is documenting a patient's response to pain medication. Which entry best reflects objective documentation?

Accepted Answer

Patient states pain decreased from 8/10 to 3/10 after medication

Answer

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?

Accepted Answer

A patient falls out of bed during the shift

Answer

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?

Accepted Answer

Recommendation

Answer

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?

Accepted Answer

Draw a single line through the error, write 'error,' initial, and date it

Answer

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?

Accepted Answer

Read back the complete order to the physician for verification

Answer

Read-back of telephone orders is a critical safety step that allows the prescriber to confirm accuracy before implementation.

(Next) National Exit Test Practice Test

(Next) National Exit Test Practice Test

Next Communication and Documentation 2