NURSING DOCUMENTATION AND COMMUNICATION EXAM REVIEW
2026 / COMPLETE NURSING STUDY GUIDE WITH PRACTICE QUESTIONS,
ANSWERS AND RATIONALES
1. A nurse is documenting the admission assessment of a client who reports
severe abdominal pain, nausea, and dizziness. Which documentation entry
most appropriately reflects objective and subjective assessment findings
while avoiding unsupported conclusions?
A. Client appears to have a serious gastrointestinal disorder and is probably
dehydrated.
B. Client reports abdominal pain rated 8/10 and nausea; skin cool and
moist, blood pressure 96/58 mm Hg, pulse 112/min, and urine output 20
mL over the previous hour.
C. Client is very sick, uncomfortable, and possibly experiencing shock from
an abdominal problem.
D. Client has severe abdominal pathology with inadequate fluid volume and
requires immediate treatment.
2. During a change-of-shift report, a nurse must communicate information
about a client who developed sudden shortness of breath during the
previous hour. Which information should be emphasized first to promote
safe continuity of care?
A. The client requested that the room temperature be lowered.
B. The client has been hospitalized for three days.
C. The client usually enjoys watching television in the evening.
D. The client developed sudden dyspnea, oxygen saturation decreased from
96% to 88%, respiratory rate is 30/min, and the provider was notified.
3. A nurse realizes immediately after administering a medication that the
wrong dose was given. The client currently has no symptoms. Which action
is most appropriate regarding documentation?
A. Document the medication error objectively, assess the client, notify the
appropriate provider and supervisor according to policy, and complete
required safety reporting.
pg. 1
, B. Avoid documenting the error because the client has no symptoms and
the medication was already administered.
C. Record that the provider prescribed the incorrect dose even though the
nurse administered the dose.
D. Delete the medication entry and replace it with the dose that should
have been administered.
4. A nurse is documenting a client's wound assessment after a dressing
change. Which entry demonstrates the most appropriate objective
documentation?
A. Wound looks much better today and appears to be healing normally.
B. Wound is infected and probably needs stronger antibiotics.
C. Surgical wound measures 3 cm × 2 cm × 0.5 cm; wound bed pink with
scant serous drainage; surrounding skin intact without erythema.
D. Client has a bad-looking wound that seems painful and infected.
5. A nurse receives a verbal prescription from a provider in a situation in which
immediate treatment is required. Which communication technique best
reduces the risk of misunderstanding the prescription?
A. Accept the prescription without repeating it because the provider is
familiar with the client.
B. Repeat the prescription back to the provider, clarify any uncertainty, and
document the verbal prescription according to organizational policy.
C. Ask another nurse to remember the prescription and enter it later.
D. Write down only the medication name and rely on memory for the
remaining details.
6. A nurse is caring for four clients and receives a laboratory result indicating
that one client has a critically low potassium level. Which communication
action should the nurse prioritize?
A. Place the laboratory report in the chart and discuss it during the next
routine interdisciplinary meeting.
B. Wait until the next scheduled nursing handoff so the oncoming nurse can
notify the provider.
pg. 2
, C. Notify the appropriate provider promptly using a structured
communication method and document the assessment and notification.
D. Record the laboratory result without contacting anyone because
laboratory personnel are responsible for critical-value notifications.
7. A nurse is documenting a client's statement that pain began after
ambulation and feels like pressure in the center of the chest. Which
documentation is most appropriate?
A. Client states, “The pain started after I walked and feels like pressure in
the center of my chest.”
B. Client is having an acute myocardial infarction after walking.
C. Client has cardiac pain caused by exertion.
D. Client probably has angina because the symptoms are typical.
8. During a telephone report, the receiving nurse asks the sending nurse to
clarify the client's current status. Which response demonstrates effective
professional communication?
A. “Everything is fine, so there is nothing important to report.”
B. “You can just read the chart because all the information is already there.”
C. “The client has been stable,” without providing current assessment
findings.
D. “The client is currently alert, blood pressure is 118/72 mm Hg, pulse
84/min, oxygen saturation 95% on room air, and pain is 3/10 after receiving
prescribed analgesia.”
9. A nurse enters an incorrect assessment value into an electronic health
record and notices the error before the end of the shift. Which action is
appropriate?
A. Leave the incorrect entry because electronic records cannot be
corrected.
B. Correct the entry using the electronic record's approved correction
procedure while preserving the original entry and identifying the correction
appropriately.
C. Delete the entire assessment and enter a new assessment without
pg. 3
, mentioning the correction.
D. Ask another nurse to log into the system and correct the entry.
10. A nurse is preparing to transfer a client from a medical unit to a higher-
acuity setting because of worsening respiratory status. Which information is
most important to communicate during the transfer?
A. The client's preferred television programs and usual bedtime.
B. The client's dietary preferences from the previous day.
C. The client's current respiratory assessment, oxygen requirements, recent
changes, interventions performed, response to treatment, allergies, and
pending orders.
D. The names of all nurses who cared for the client during the
hospitalization.
11. A nurse documents that a client is “noncompliant with treatment.” Why
should this type of wording generally be avoided?
A. It is an objective description that provides sufficient clinical information.
B. It communicates the exact intervention that the client refused.
C. It eliminates the need to document the client's statements.
D. It is judgmental and does not explain the client's actual behavior,
understanding, concerns, or reason for declining treatment.
12. A client refuses a prescribed dressing change after the nurse explains its
purpose and possible consequences. Which documentation is most
appropriate?
A. Client refused dressing change because client is difficult.
B. Client stated, “I do not want the dressing changed today,” after the
procedure and risks were explained; provider notified according to policy.
C. Client was noncompliant and refused necessary treatment.
D. Dressing change could not be completed because the client was
uncooperative.
13. A nurse is using SBAR to communicate a sudden change in a client's
condition. What information belongs in the “Assessment” portion of SBAR?
A. The nurse's interpretation of the client's current clinical condition based
pg. 4
2026 / COMPLETE NURSING STUDY GUIDE WITH PRACTICE QUESTIONS,
ANSWERS AND RATIONALES
1. A nurse is documenting the admission assessment of a client who reports
severe abdominal pain, nausea, and dizziness. Which documentation entry
most appropriately reflects objective and subjective assessment findings
while avoiding unsupported conclusions?
A. Client appears to have a serious gastrointestinal disorder and is probably
dehydrated.
B. Client reports abdominal pain rated 8/10 and nausea; skin cool and
moist, blood pressure 96/58 mm Hg, pulse 112/min, and urine output 20
mL over the previous hour.
C. Client is very sick, uncomfortable, and possibly experiencing shock from
an abdominal problem.
D. Client has severe abdominal pathology with inadequate fluid volume and
requires immediate treatment.
2. During a change-of-shift report, a nurse must communicate information
about a client who developed sudden shortness of breath during the
previous hour. Which information should be emphasized first to promote
safe continuity of care?
A. The client requested that the room temperature be lowered.
B. The client has been hospitalized for three days.
C. The client usually enjoys watching television in the evening.
D. The client developed sudden dyspnea, oxygen saturation decreased from
96% to 88%, respiratory rate is 30/min, and the provider was notified.
3. A nurse realizes immediately after administering a medication that the
wrong dose was given. The client currently has no symptoms. Which action
is most appropriate regarding documentation?
A. Document the medication error objectively, assess the client, notify the
appropriate provider and supervisor according to policy, and complete
required safety reporting.
pg. 1
, B. Avoid documenting the error because the client has no symptoms and
the medication was already administered.
C. Record that the provider prescribed the incorrect dose even though the
nurse administered the dose.
D. Delete the medication entry and replace it with the dose that should
have been administered.
4. A nurse is documenting a client's wound assessment after a dressing
change. Which entry demonstrates the most appropriate objective
documentation?
A. Wound looks much better today and appears to be healing normally.
B. Wound is infected and probably needs stronger antibiotics.
C. Surgical wound measures 3 cm × 2 cm × 0.5 cm; wound bed pink with
scant serous drainage; surrounding skin intact without erythema.
D. Client has a bad-looking wound that seems painful and infected.
5. A nurse receives a verbal prescription from a provider in a situation in which
immediate treatment is required. Which communication technique best
reduces the risk of misunderstanding the prescription?
A. Accept the prescription without repeating it because the provider is
familiar with the client.
B. Repeat the prescription back to the provider, clarify any uncertainty, and
document the verbal prescription according to organizational policy.
C. Ask another nurse to remember the prescription and enter it later.
D. Write down only the medication name and rely on memory for the
remaining details.
6. A nurse is caring for four clients and receives a laboratory result indicating
that one client has a critically low potassium level. Which communication
action should the nurse prioritize?
A. Place the laboratory report in the chart and discuss it during the next
routine interdisciplinary meeting.
B. Wait until the next scheduled nursing handoff so the oncoming nurse can
notify the provider.
pg. 2
, C. Notify the appropriate provider promptly using a structured
communication method and document the assessment and notification.
D. Record the laboratory result without contacting anyone because
laboratory personnel are responsible for critical-value notifications.
7. A nurse is documenting a client's statement that pain began after
ambulation and feels like pressure in the center of the chest. Which
documentation is most appropriate?
A. Client states, “The pain started after I walked and feels like pressure in
the center of my chest.”
B. Client is having an acute myocardial infarction after walking.
C. Client has cardiac pain caused by exertion.
D. Client probably has angina because the symptoms are typical.
8. During a telephone report, the receiving nurse asks the sending nurse to
clarify the client's current status. Which response demonstrates effective
professional communication?
A. “Everything is fine, so there is nothing important to report.”
B. “You can just read the chart because all the information is already there.”
C. “The client has been stable,” without providing current assessment
findings.
D. “The client is currently alert, blood pressure is 118/72 mm Hg, pulse
84/min, oxygen saturation 95% on room air, and pain is 3/10 after receiving
prescribed analgesia.”
9. A nurse enters an incorrect assessment value into an electronic health
record and notices the error before the end of the shift. Which action is
appropriate?
A. Leave the incorrect entry because electronic records cannot be
corrected.
B. Correct the entry using the electronic record's approved correction
procedure while preserving the original entry and identifying the correction
appropriately.
C. Delete the entire assessment and enter a new assessment without
pg. 3
, mentioning the correction.
D. Ask another nurse to log into the system and correct the entry.
10. A nurse is preparing to transfer a client from a medical unit to a higher-
acuity setting because of worsening respiratory status. Which information is
most important to communicate during the transfer?
A. The client's preferred television programs and usual bedtime.
B. The client's dietary preferences from the previous day.
C. The client's current respiratory assessment, oxygen requirements, recent
changes, interventions performed, response to treatment, allergies, and
pending orders.
D. The names of all nurses who cared for the client during the
hospitalization.
11. A nurse documents that a client is “noncompliant with treatment.” Why
should this type of wording generally be avoided?
A. It is an objective description that provides sufficient clinical information.
B. It communicates the exact intervention that the client refused.
C. It eliminates the need to document the client's statements.
D. It is judgmental and does not explain the client's actual behavior,
understanding, concerns, or reason for declining treatment.
12. A client refuses a prescribed dressing change after the nurse explains its
purpose and possible consequences. Which documentation is most
appropriate?
A. Client refused dressing change because client is difficult.
B. Client stated, “I do not want the dressing changed today,” after the
procedure and risks were explained; provider notified according to policy.
C. Client was noncompliant and refused necessary treatment.
D. Dressing change could not be completed because the client was
uncooperative.
13. A nurse is using SBAR to communicate a sudden change in a client's
condition. What information belongs in the “Assessment” portion of SBAR?
A. The nurse's interpretation of the client's current clinical condition based
pg. 4
