Newest NSG 3180 – Communication & Teamwork EXAM 2 questions
verified with correct answers plus rationales( galen)
1. A nurse is documenting information in the electronic health record while sitting at the
client's bedside. Which action best promotes patient engagement?
A. Focus entirely on the computer
B. Avoid speaking while documenting
C. Explain what is being documented and maintain appropriate eye contact with the client
D. Complete all documentation after the client leaves
Answer: C. Explain what is being documented and maintain appropriate eye contact with
the client
Rationale: Maintaining eye contact and explaining documentation helps preserve the therapeutic
relationship while allowing the client to participate in verifying information.
2. Which is a major purpose of an electronic health record (EHR)?
A. Eliminate communication among healthcare professionals
B. Replace clinical judgment
C. Improve access to patient information and support coordinated, safer care
D. Prevent patients from accessing their health information
Answer: C. Improve access to patient information and support coordinated, safer care
Rationale: EHRs facilitate access to patient information, communication, care coordination, and
clinical decision-making.
3. Which finding represents a potential barrier to successful EHR implementation?
A. Improved information sharing
B. Better access to records
C. Resistance from healthcare providers who are unfamiliar or uncomfortable with the
technology
D. Improved coordination of care
Answer: C. Resistance from healthcare providers who are unfamiliar or uncomfortable
with the technology
,Rationale: Resistance to change, inadequate training, connectivity problems, security concerns,
and interoperability difficulties can interfere with EHR implementation.
4. A nurse enters incorrect information into a client's EHR. What should the nurse do?
A. Delete the entire record
B. Ignore the error
C. Correct the documentation according to organizational policy while maintaining the
integrity of the record
D. Ask another nurse to change it
Answer: C. Correct the documentation according to organizational policy while
maintaining the integrity of the record
Rationale: Documentation corrections must be accurate, traceable, and consistent with legal
and organizational requirements.
5. Which documentation entry is most appropriate?
A. “Patient had a bad day.”
B. “Patient seems upset.”
C. “Client states, ‘I am worried about my surgery.’ Client is tearful and asks several
questions about the procedure.”
D. “Client is acting strangely.”
Answer: C. “Client states, ‘I am worried about my surgery.’ Client is tearful and asks
several questions about the procedure.”
Rationale: This entry separates the client's statement from observable findings and avoids vague
or judgmental language.
6. A nurse receives confidential patient information through the EHR. Which action is
appropriate?
A. Share the information with friends
B. Access records of patients out of curiosity
C. Access only information necessary for the nurse's assigned responsibilities
D. Print records and leave them at the nurses' station
Answer: C. Access only information necessary for the nurse's assigned responsibilities
,Rationale: Patient information should be accessed and disclosed only for legitimate care-related
purposes.
7. Which action is an appropriate use of secure healthcare technology?
A. Discussing a patient's diagnosis on social media
B. Sending patient information through a personal messaging application
C. Communicating protected health information through an approved secure clinical
system
D. Posting patient information anonymously online
Answer: C. Communicating protected health information through an approved secure
clinical system
Rationale: Approved secure systems help protect patient confidentiality and privacy.
8. What does interoperability mean in healthcare information technology?
A. A computer cannot communicate with another system
B. Different healthcare information systems can exchange and use information
appropriately
C. Patients cannot access electronic records
D. Only one healthcare professional can access a record
Answer: B. Different healthcare information systems can exchange and use information
appropriately
Rationale: Interoperability allows healthcare systems to exchange and meaningfully use
information across platforms.
9. Which statement about electronic health records is accurate?
A. EHRs eliminate the need for nursing assessment
B. EHRs guarantee that errors never occur
C. EHRs can improve communication and coordination when information is entered
accurately
D. EHRs eliminate the need for patient education
Answer: C. EHRs can improve communication and coordination when information is
entered accurately
, Rationale: EHRs are tools that support care; their effectiveness depends on accurate
documentation and appropriate use.
10. A nurse notices that an important assessment finding is missing from the EHR. What
should the nurse do?
A. Assume another nurse documented it
B. Leave it undocumented
C. Complete accurate documentation according to policy as soon as possible
D. Enter an estimated finding
Answer: C. Complete accurate documentation according to policy as soon as possible
Rationale: Complete and timely documentation supports continuity of care and patient safety.
11. A nurse needs to communicate a client's deteriorating condition to a healthcare
provider. Which communication format is most appropriate?
A. SOAP only
B. SBAR
C. Informal conversation
D. Social media message
Answer: B. SBAR
Rationale: SBAR provides a structured method for communicating important clinical
information.
12. In SBAR communication, what does the “S” represent?
A. Safety
B. Summary
C. Situation
D. Solution
Answer: C. Situation
Rationale: Situation identifies the immediate problem or reason for the communication.
verified with correct answers plus rationales( galen)
1. A nurse is documenting information in the electronic health record while sitting at the
client's bedside. Which action best promotes patient engagement?
A. Focus entirely on the computer
B. Avoid speaking while documenting
C. Explain what is being documented and maintain appropriate eye contact with the client
D. Complete all documentation after the client leaves
Answer: C. Explain what is being documented and maintain appropriate eye contact with
the client
Rationale: Maintaining eye contact and explaining documentation helps preserve the therapeutic
relationship while allowing the client to participate in verifying information.
2. Which is a major purpose of an electronic health record (EHR)?
A. Eliminate communication among healthcare professionals
B. Replace clinical judgment
C. Improve access to patient information and support coordinated, safer care
D. Prevent patients from accessing their health information
Answer: C. Improve access to patient information and support coordinated, safer care
Rationale: EHRs facilitate access to patient information, communication, care coordination, and
clinical decision-making.
3. Which finding represents a potential barrier to successful EHR implementation?
A. Improved information sharing
B. Better access to records
C. Resistance from healthcare providers who are unfamiliar or uncomfortable with the
technology
D. Improved coordination of care
Answer: C. Resistance from healthcare providers who are unfamiliar or uncomfortable
with the technology
,Rationale: Resistance to change, inadequate training, connectivity problems, security concerns,
and interoperability difficulties can interfere with EHR implementation.
4. A nurse enters incorrect information into a client's EHR. What should the nurse do?
A. Delete the entire record
B. Ignore the error
C. Correct the documentation according to organizational policy while maintaining the
integrity of the record
D. Ask another nurse to change it
Answer: C. Correct the documentation according to organizational policy while
maintaining the integrity of the record
Rationale: Documentation corrections must be accurate, traceable, and consistent with legal
and organizational requirements.
5. Which documentation entry is most appropriate?
A. “Patient had a bad day.”
B. “Patient seems upset.”
C. “Client states, ‘I am worried about my surgery.’ Client is tearful and asks several
questions about the procedure.”
D. “Client is acting strangely.”
Answer: C. “Client states, ‘I am worried about my surgery.’ Client is tearful and asks
several questions about the procedure.”
Rationale: This entry separates the client's statement from observable findings and avoids vague
or judgmental language.
6. A nurse receives confidential patient information through the EHR. Which action is
appropriate?
A. Share the information with friends
B. Access records of patients out of curiosity
C. Access only information necessary for the nurse's assigned responsibilities
D. Print records and leave them at the nurses' station
Answer: C. Access only information necessary for the nurse's assigned responsibilities
,Rationale: Patient information should be accessed and disclosed only for legitimate care-related
purposes.
7. Which action is an appropriate use of secure healthcare technology?
A. Discussing a patient's diagnosis on social media
B. Sending patient information through a personal messaging application
C. Communicating protected health information through an approved secure clinical
system
D. Posting patient information anonymously online
Answer: C. Communicating protected health information through an approved secure
clinical system
Rationale: Approved secure systems help protect patient confidentiality and privacy.
8. What does interoperability mean in healthcare information technology?
A. A computer cannot communicate with another system
B. Different healthcare information systems can exchange and use information
appropriately
C. Patients cannot access electronic records
D. Only one healthcare professional can access a record
Answer: B. Different healthcare information systems can exchange and use information
appropriately
Rationale: Interoperability allows healthcare systems to exchange and meaningfully use
information across platforms.
9. Which statement about electronic health records is accurate?
A. EHRs eliminate the need for nursing assessment
B. EHRs guarantee that errors never occur
C. EHRs can improve communication and coordination when information is entered
accurately
D. EHRs eliminate the need for patient education
Answer: C. EHRs can improve communication and coordination when information is
entered accurately
, Rationale: EHRs are tools that support care; their effectiveness depends on accurate
documentation and appropriate use.
10. A nurse notices that an important assessment finding is missing from the EHR. What
should the nurse do?
A. Assume another nurse documented it
B. Leave it undocumented
C. Complete accurate documentation according to policy as soon as possible
D. Enter an estimated finding
Answer: C. Complete accurate documentation according to policy as soon as possible
Rationale: Complete and timely documentation supports continuity of care and patient safety.
11. A nurse needs to communicate a client's deteriorating condition to a healthcare
provider. Which communication format is most appropriate?
A. SOAP only
B. SBAR
C. Informal conversation
D. Social media message
Answer: B. SBAR
Rationale: SBAR provides a structured method for communicating important clinical
information.
12. In SBAR communication, what does the “S” represent?
A. Safety
B. Summary
C. Situation
D. Solution
Answer: C. Situation
Rationale: Situation identifies the immediate problem or reason for the communication.
