NUR 1400 EXAM 2 DOCUMENTATION 2026/2027 | NURSING STUDY
GUIDE, PRACTICE QUESTIONS, ANSWERS & EXAM REVIEW
Assertiveness - ✔✔- confined, open body posture
-eye contact
- use of clean, concise "I" statements
- the ability to share through, feelings, and emotions
-attitude toward work is characterized by working to capacity with or without supervision
-the ability to remain calm under supervision
-the freedom to ask for help when necessary
-the ability to give and accept compliments
-honesty in admitting mistakes and taking responsibility for them
documenting and reporting - ✔✔What are the two main communications in nursing
- identity/introduction
- situation
- background
- assessment
- recommendation/ request
- questions - ✔✔What is ISBARQ?
Situation
Background
Assessment
Recommendation - ✔✔What is SBAR?
- Change-of-shift report of handoff report
- transfer
- discharge
- telephone reports (labs, imaging, providers)
- Reports to family members and significant others - ✔✔When does reporting occur?
- If the patient is unable to communicate information
- Information should be shared in a manner that is honest, compassionate, and respectful of the person's
ability to understand medical concepts - ✔✔When can a nurse give report to family members and
significant others?
Purposeful rounds - ✔✔involves repositioning, toileting, personal needs, and pain present
ADPIE - ✔✔Documentation is a written or electronic record of all pertinent interactions with the pt:
Patient's health information - ✔✔PHI
crucial omissions and meaningless repetitious or inaccurate entries - ✔✔What should be avoided when
documenting?
GUIDE, PRACTICE QUESTIONS, ANSWERS & EXAM REVIEW
Assertiveness - ✔✔- confined, open body posture
-eye contact
- use of clean, concise "I" statements
- the ability to share through, feelings, and emotions
-attitude toward work is characterized by working to capacity with or without supervision
-the ability to remain calm under supervision
-the freedom to ask for help when necessary
-the ability to give and accept compliments
-honesty in admitting mistakes and taking responsibility for them
documenting and reporting - ✔✔What are the two main communications in nursing
- identity/introduction
- situation
- background
- assessment
- recommendation/ request
- questions - ✔✔What is ISBARQ?
Situation
Background
Assessment
Recommendation - ✔✔What is SBAR?
- Change-of-shift report of handoff report
- transfer
- discharge
- telephone reports (labs, imaging, providers)
- Reports to family members and significant others - ✔✔When does reporting occur?
- If the patient is unable to communicate information
- Information should be shared in a manner that is honest, compassionate, and respectful of the person's
ability to understand medical concepts - ✔✔When can a nurse give report to family members and
significant others?
Purposeful rounds - ✔✔involves repositioning, toileting, personal needs, and pain present
ADPIE - ✔✔Documentation is a written or electronic record of all pertinent interactions with the pt:
Patient's health information - ✔✔PHI
crucial omissions and meaningless repetitious or inaccurate entries - ✔✔What should be avoided when
documenting?
