NSG 521 EXAM 1 2025/2026 ACCURATE FALL-
SPRING SEMESTER COMPLETE QUESTION
AND ANSWER (ORIGINAL)
What is the purpose of documentation?
To provide a legal record of care, ensure continuity, improve communication, and meet legal
and regulatory requirements.
What are the principles nurses should know to ensure appropriate documentation?
-Be accurate, clear, and concise. Use exact quotes from patients and providers if needed
-Document within a timely manner. Do not wait until the end of your shift to document.
-Use objective, factual information.
-Include date, time, and signature.
-Avoid assumptions or personal opinions.
-Document everything as if you are going to court (your license depends on it)
What guides what a nurse can and cannot do?
Nurse Practice Act
What is ISBAR/SBAR communication?
A standardized communication tool is used in healthcare settings to ensure clear and effective
communication, particularly during handoffs or when conveying critical information to other
healthcare providers. It can be used when giving report to another nurse or when contacting a
provider.
Identity, Situation, Background, Assessment, Recommendation
Summarize the components of ISBAR.
, I - Identification: Identify yourself, your role, and the patient.
Example: "This is Jane, the RN on the surgical floor, calling about Mr. Smith, room 302."
S - Situation: Describe the current situation or the reason for the communication.
Example: "Mr. Smith's blood pressure has dropped to 90/50, and he's feeling lightheaded."
B - Background: Provide relevant patient background or history.
Example: "He had surgery two days ago for a hip replacement, and his previous vitals were
stable at 116/78."
A - Assessment: Share your assessment or observations about the situation.
Example: "I think he may be experiencing postoperative hypotension."
R - Recommendation: Suggest what should be done next or what action is needed.
Example: "I recommend increasing fluids and reassessing his vitals in 15 minutes. Would you
like to order any further tests?"
What is therapeutic communication?
Intentional communication aimed at promoting patient well-being. It involves active listening,
empathy, and techniques like open-ended questions and reflection.
How do you create trust with a patient?
Demonstrating empathy.
Maintaining confidentiality.
Being reliable and following through on promises.
Actively listening to their concerns
What is the difference between subjective and objective data?
Subjective data is what the patient says about their condition (symptoms); Objective data is
what the nurse observes or measures (signs).
What are nursing diagnoses?
SPRING SEMESTER COMPLETE QUESTION
AND ANSWER (ORIGINAL)
What is the purpose of documentation?
To provide a legal record of care, ensure continuity, improve communication, and meet legal
and regulatory requirements.
What are the principles nurses should know to ensure appropriate documentation?
-Be accurate, clear, and concise. Use exact quotes from patients and providers if needed
-Document within a timely manner. Do not wait until the end of your shift to document.
-Use objective, factual information.
-Include date, time, and signature.
-Avoid assumptions or personal opinions.
-Document everything as if you are going to court (your license depends on it)
What guides what a nurse can and cannot do?
Nurse Practice Act
What is ISBAR/SBAR communication?
A standardized communication tool is used in healthcare settings to ensure clear and effective
communication, particularly during handoffs or when conveying critical information to other
healthcare providers. It can be used when giving report to another nurse or when contacting a
provider.
Identity, Situation, Background, Assessment, Recommendation
Summarize the components of ISBAR.
, I - Identification: Identify yourself, your role, and the patient.
Example: "This is Jane, the RN on the surgical floor, calling about Mr. Smith, room 302."
S - Situation: Describe the current situation or the reason for the communication.
Example: "Mr. Smith's blood pressure has dropped to 90/50, and he's feeling lightheaded."
B - Background: Provide relevant patient background or history.
Example: "He had surgery two days ago for a hip replacement, and his previous vitals were
stable at 116/78."
A - Assessment: Share your assessment or observations about the situation.
Example: "I think he may be experiencing postoperative hypotension."
R - Recommendation: Suggest what should be done next or what action is needed.
Example: "I recommend increasing fluids and reassessing his vitals in 15 minutes. Would you
like to order any further tests?"
What is therapeutic communication?
Intentional communication aimed at promoting patient well-being. It involves active listening,
empathy, and techniques like open-ended questions and reflection.
How do you create trust with a patient?
Demonstrating empathy.
Maintaining confidentiality.
Being reliable and following through on promises.
Actively listening to their concerns
What is the difference between subjective and objective data?
Subjective data is what the patient says about their condition (symptoms); Objective data is
what the nurse observes or measures (signs).
What are nursing diagnoses?
