Communication and Documentation Flashcards
7 cards from real NMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Communication and Documentation flashcards as text
A patient with limited English proficiency requires discharge teaching. What is the most appropriate action?
Answer: Use a professional interpreter service
Professional interpreter services ensure accurate, confidential communication and are required by NMC standards when a language barrier exists.
Which of the following best describes a SBAR communication tool?
Answer: Situation, Background, Assessment, Recommendation
SBAR stands for Situation, Background, Assessment, Recommendation and is a structured handover tool endorsed by NMC.
A nurse discovers a medication error was not documented by the previous shift. What should the nurse do?
Answer: Document the error with today's date and time, noting it occurred during the previous shift
Late entries must be recorded accurately with the actual time of the event and the time of documentation to maintain transparency.
When is it appropriate for a nurse to break patient confidentiality without consent?
Answer: When there is a serious risk of harm to the patient or others
NMC Code permits disclosure without consent only when there is a serious, credible risk of harm to the patient or a third party.
A patient refuses to have their care discussed in front of a student nurse. The nurse should:
Answer: Respect the patient's decision and ask the student to leave
Patients have the right to control who is present during their care discussions; respecting this upholds dignity and the NMC Code.
Which statement about electronic nursing records is most accurate?
Answer: Electronic records must be accurate, legible, and only altered by authorized personnel
NMC standards apply equally to electronic records; they must be accurate, and entries should only be made or amended by authorized individuals with audit trails.
During a clinical handover, the oncoming nurse should:
Answer: Actively clarify any unclear or incomplete information received
Active clarification during handover is essential to patient safety and is a core NMC expectation for effective communication.