NURS 121L-B Medical-Surgical Nursing Practicum: Documentation &
SBAR Mastery 2026 |WCU
1. A nurse is documenting a patient’s response to an analgesic. Which entry
represents the most accurate and objective clinical documentation?
A. Patient states pain is 3/10 one hour after administration of Morphine 2mg IV.
B. Patient seems to be feeling much better after the medication.
C. Administered pain meds; patient is resting comfortably now.
D. The medication was effective and the patient is satisfied.
Answer: A
Rationale: Effective documentation must be objective and measurable. Option B includes
the patient’s self-report using a scale, the specific drug, dose, route, and timing, which is the
gold standard for nursing notes.
2. During an SBAR report, the nurse states: ‘The patient’s heart rate has
increased from 80 to 120 bpm, and the blood pressure has dropped to 90/50
mmHg.’ Which component of SBAR does this represent?
A. Assessment
B. Background
C. Situation
D. Recommendation
Answer: A
Rationale: Assessment in SBAR involves the nurse’s clinical findings and analysis of the
current situation, including vital sign changes and physical exam data.
,3. A nursing student is reviewing the ‘Do Not Use’ list of abbreviations. Which of
the following is an unacceptable abbreviation according to The Joint
Commission?
A. q.d.
B. PO
C. NPO
D. mL
Answer: A
Rationale: ‘q.d.’ (daily) is on the Do Not Use list because it can be mistaken for ‘q.i.d.’
Nurses must write ‘daily’ instead.
4. Which legal principle best explains why a nurse must document all care
provided in a timely manner?
A. If it wasn’t charted, it wasn’t done.
B. Res ipsa loquitur
C. Beneficence
D. Statute of limitations
Answer: A
Rationale: In a court of law, nursing documentation is the only evidence that care was
provided. If an action is not documented, the legal assumption is that the intervention did
not occur.
5. While using Focus Charting (DAR), what does the ‘D’ represent?
A. Diagnosis
B. Decision
C. Data
D. Description
Answer: C
, Rationale: Focus Charting uses the DAR format: Data (subjective/objective), Action
(interventions), and Response (evaluation).
6. A nurse discovers she made an error in a handwritten narrative note. What is
the correct action to take?
A. Use white-out to cover the error and write over it.
B. Scribble out the text so it is completely unreadable.
C. Draw a single line through the error, write ‘error,’ and initial it.
D. Discard the page and start the entire chart over.
Answer: C
Rationale: Legal standards require a single line through an error to maintain the integrity
of the record, accompanied by the nurse’s initials and the word ‘error’ or ‘mistaken entry.’
7. When communicating with a physician about a patient’s deteriorating
condition, the nurse suggests: ‘I believe the patient needs an urgent Chest X-ray
and an ABG.’ This fits which SBAR category?
A. Situation
B. Background
C. Assessment
D. Recommendation
Answer: D
Rationale: The Recommendation phase is where the nurse suggests a specific action or
intervention to address the problem.
8. What is the primary purpose of an incident (occurrence) report?
A. To provide grounds for disciplinary action against staff.
B. To identify system failures and improve quality of care.
C. To serve as a legal document in the patient’s permanent record.
D. To notify the patient’s family about a medical error.
Answer: B
SBAR Mastery 2026 |WCU
1. A nurse is documenting a patient’s response to an analgesic. Which entry
represents the most accurate and objective clinical documentation?
A. Patient states pain is 3/10 one hour after administration of Morphine 2mg IV.
B. Patient seems to be feeling much better after the medication.
C. Administered pain meds; patient is resting comfortably now.
D. The medication was effective and the patient is satisfied.
Answer: A
Rationale: Effective documentation must be objective and measurable. Option B includes
the patient’s self-report using a scale, the specific drug, dose, route, and timing, which is the
gold standard for nursing notes.
2. During an SBAR report, the nurse states: ‘The patient’s heart rate has
increased from 80 to 120 bpm, and the blood pressure has dropped to 90/50
mmHg.’ Which component of SBAR does this represent?
A. Assessment
B. Background
C. Situation
D. Recommendation
Answer: A
Rationale: Assessment in SBAR involves the nurse’s clinical findings and analysis of the
current situation, including vital sign changes and physical exam data.
,3. A nursing student is reviewing the ‘Do Not Use’ list of abbreviations. Which of
the following is an unacceptable abbreviation according to The Joint
Commission?
A. q.d.
B. PO
C. NPO
D. mL
Answer: A
Rationale: ‘q.d.’ (daily) is on the Do Not Use list because it can be mistaken for ‘q.i.d.’
Nurses must write ‘daily’ instead.
4. Which legal principle best explains why a nurse must document all care
provided in a timely manner?
A. If it wasn’t charted, it wasn’t done.
B. Res ipsa loquitur
C. Beneficence
D. Statute of limitations
Answer: A
Rationale: In a court of law, nursing documentation is the only evidence that care was
provided. If an action is not documented, the legal assumption is that the intervention did
not occur.
5. While using Focus Charting (DAR), what does the ‘D’ represent?
A. Diagnosis
B. Decision
C. Data
D. Description
Answer: C
, Rationale: Focus Charting uses the DAR format: Data (subjective/objective), Action
(interventions), and Response (evaluation).
6. A nurse discovers she made an error in a handwritten narrative note. What is
the correct action to take?
A. Use white-out to cover the error and write over it.
B. Scribble out the text so it is completely unreadable.
C. Draw a single line through the error, write ‘error,’ and initial it.
D. Discard the page and start the entire chart over.
Answer: C
Rationale: Legal standards require a single line through an error to maintain the integrity
of the record, accompanied by the nurse’s initials and the word ‘error’ or ‘mistaken entry.’
7. When communicating with a physician about a patient’s deteriorating
condition, the nurse suggests: ‘I believe the patient needs an urgent Chest X-ray
and an ABG.’ This fits which SBAR category?
A. Situation
B. Background
C. Assessment
D. Recommendation
Answer: D
Rationale: The Recommendation phase is where the nurse suggests a specific action or
intervention to address the problem.
8. What is the primary purpose of an incident (occurrence) report?
A. To provide grounds for disciplinary action against staff.
B. To identify system failures and improve quality of care.
C. To serve as a legal document in the patient’s permanent record.
D. To notify the patient’s family about a medical error.
Answer: B
