NACE Communication and Documentation 4 — Questions and Answers
Question 1: In the SBAR communication format, what information goes in the 'B' section?
- The nurse's assessment of the current problem
- Pertinent history such as admitting diagnosis, relevant labs, and current treatments (Correct answer)
- The nurse's recommendation for what should be done
- A brief statement of the immediate concern
Correct 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.
Question 2: A provider gives a telephone order for a new medication. What is the nurse's priority action?
- Write the order down, read it back to the provider, and get confirmation (Correct answer)
- Repeat the medication name only
- Have the unit secretary take the order
- Give the medication and document it at the end of the shift
Correct 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.
Question 3: Which practice best supports safe shift-to-shift handoff communication?
- Recording a report and leaving before the oncoming nurse arrives
- Giving report at the nurses' station in a hallway full of visitors
- Using a standardized tool, at the bedside when possible, with time for questions (Correct answer)
- Sharing only the information the off-going nurse thinks is important
Correct 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.
Question 4: As an LPN transitions to the RN role, which documentation responsibility belongs to the RN rather than the LPN?
- Recording vital signs
- Charting medications given
- Documenting the client's oral intake
- Completing the initial comprehensive admission assessment and nursing care plan (Correct answer)
Correct 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.
Question 5: 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?
- Wait until the next set of labs to confirm the value
- Document the critical value, the time, the name of the person notified, and any orders received (Correct answer)
- Document only the lab value in the flow sheet
- Tell the charge nurse instead of documenting
Correct 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.
Question 6: A nurse pages a provider twice about a client's falling blood pressure and gets no response. What should the nurse do next?
- Keep monitoring and page again in an hour
- Document that the provider did not respond and wait
- Follow the chain of command by notifying the charge nurse or nursing supervisor (Correct answer)
- Give an IV fluid bolus without an order
Correct 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.
Question 7: A nurse questions a medication order because the dose seems too high. Which action is most appropriate?
- Give the dose because the provider wrote it
- Give half the dose to be safe
- Ask another nurse to give the medication
- Hold the medication, clarify the order with the prescriber, and document the communication (Correct answer)
Correct 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.
