Next Communication and Documentation 3 — Questions and Answers
Question 1: A nurse is receiving a hand-off report using the I-PASS method. Which element addresses the patient's current status?
- Patient summary
- Illness severity (Correct answer)
- Action list
- Situation awareness
Correct answer: Illness severity
In I-PASS, 'Illness severity' describes whether the patient is stable, watcher, or unstable, reflecting current clinical status.
Question 2: Which documentation practice best demonstrates continuity of nursing care?
- Recording assessments, interventions, and patient responses each shift (Correct answer)
- Charting only when a significant change occurs
- Documenting at the end of the shift from memory
- Copying the previous nurse's note with minor edits
Correct answer: Recording assessments, interventions, and patient responses each shift
Consistent, shift-by-shift documentation of assessments, interventions, and outcomes shows a clear, uninterrupted picture of patient care.
Question 3: A patient asks a nurse not to share health information with any family members. The nurse should:
- Honor the request and document the patient's preference (Correct answer)
- Explain that family members have an automatic right to the information
- Notify the charge nurse and override the preference if family insists
- Share information only with the spouse
Correct answer: Honor the request and document the patient's preference
Competent adults have the right to restrict disclosure of their health information, and this preference must be respected and documented.
Question 4: Which statement about electronic health record (EHR) documentation is accurate?
- Each user must log in with unique credentials and never share passwords (Correct answer)
- Nurses may use a colleague's login if they forget their own password
- EHR entries can be deleted if an error is discovered
- Copy-paste of another clinician's note is an acceptable time-saving strategy
Correct answer: Each user must log in with unique credentials and never share passwords
Unique login credentials protect data integrity, ensure accountability, and are required by security standards for EHR systems.
Question 5: A nurse notes that a postoperative patient has become increasingly confused since the last assessment. Using SBAR, what belongs in the 'A' (Assessment) section?
- The nurse's clinical interpretation that the patient may be experiencing hypoxia or delirium (Correct answer)
- The patient's vital signs from the morning
- The surgeon's last documented note
- The patient's history of dementia
Correct answer: The nurse's clinical interpretation that the patient may be experiencing hypoxia or delirium
The Assessment component of SBAR contains the nurse's clinical judgment about what is happening with the patient.
Question 6: Which abbreviation has been identified by The Joint Commission as 'Do Not Use' due to risk of misinterpretation?
- U (for units) (Correct answer)
- PRN (as needed)
- NPO (nothing by mouth)
- BID (twice daily)
Correct answer: U (for units)
The abbreviation 'U' for units can be mistaken for '0' or '4,' leading to a tenfold medication overdose, so it must be written out as 'units.'
Question 7: A nurse is writing a nursing progress note using the DAR (Data, Action, Response) format. Which entry belongs under 'Data'?
- Patient reports pain of 7/10 in the right knee with ambulation (Correct answer)
- Administered ibuprofen 400 mg PO as ordered
- Patient ambulated 50 feet with decreased pain after intervention
- Encouraged patient to use prescribed analgesic prior to therapy
Correct answer: Patient reports pain of 7/10 in the right knee with ambulation
In the DAR format, 'Data' captures objective and subjective information gathered during the assessment.
Next Communication and Documentation 3
A nurse is receiving a hand-off report using the I-PASS method.
Which element addresses the patient's current status?