Communication and Documentation Flashcards
7 cards from real NACE 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
In the SBAR communication format, what information goes in the 'B' section?
Answer: Pertinent history such as admitting diagnosis, relevant labs, and current treatments
Background gives the relevant clinical context, such as diagnosis, history, medications, and recent results.
A provider gives a telephone order for a new medication. What is the nurse's priority action?
Answer: Write the order down, read it back to the provider, and get confirmation
The write-down/read-back process confirms the order is accurate and is a Joint Commission patient-safety requirement.
Which practice best supports safe shift-to-shift handoff communication?
Answer: Using a standardized tool, at the bedside when possible, with time for questions
Standardized, interactive handoffs with a chance to ask questions reduce omissions and errors.
As an LPN transitions to the RN role, which documentation responsibility belongs to the RN rather than the LPN?
Answer: Completing the initial comprehensive admission assessment and nursing care plan
Comprehensive assessment and care planning are within the RN scope, and LPNs contribute data to them.
The lab calls the nurse with a critical potassium level of 6.8 mEq/L. Which action is required after the nurse notifies the provider?
Answer: Document the critical value, the time, the name of the person notified, and any orders received
Documenting critical-result communication creates a clear record that the result was reported and acted on.
A nurse pages a provider twice about a client's falling blood pressure and gets no response. What should the nurse do next?
Answer: Follow the chain of command by notifying the charge nurse or nursing supervisor
When a provider can't be reached about a worsening client, the nurse must escalate through the chain of command to protect the client.
A nurse questions a medication order because the dose seems too high. Which action is most appropriate?
Answer: Hold the medication, clarify the order with the prescriber, and document the communication
Nurses are legally responsible for clarifying orders they believe are unsafe before giving them.
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