BSN 235
Nursing Communication &
Informatics
Final Exam Review
(With Solutions)
2025
Multiple Choice
A nurse is using SBAR (Situation, Background, Assessment, Recommendation)
to communicate a patient’s worsening condition to a physician. Which part of
SBAR ensures the nurse gives their clinical judgment about the problem?
a) Situation
b) Background
c) Assessment
d) Recommendation ANS: c) Assessment Rationale: Assessment involves the
nurse's evaluation or clinical judgment about the patient's problem.
Which of the following best describes the primary function of a Nursing
Information System (NIS) in a clinical setting?
a) Documenting patient billing information
b) Automating medication dispensing only
c) Supporting nursing documentation, care planning, and decision making
d) Managing environmental services ANS: c) Supporting nursing
documentation, care planning, and decision making Rationale: NIS are designed
to aid nurses in patient documentation, care planning, and clinical decision
support.
In a hospital using electronic health records (EHR), what communication
standard is commonly used to exchange health information between systems?
a) ISO 9001
b) HL7
c) HIPAA
d) COBIT ANS: b) HL7 Rationale: HL7 (Health Level Seven) is the
international standard for health information exchange.
During bedside shift report, a nurse asks the patient if they have any questions.
This demonstrates the communication principle of:
a) Filtering
b) Feedback
c) Encoding
d) Channeling ANS: b) Feedback Rationale: Seeking feedback ensures the
message has been understood and allows clarification.
Which of the following scenarios best demonstrates closed-loop communication
technique in nursing?
,a) A nurse giving instructions and assuming they were heard.
b) A nurse documenting patient history.
c) A nurse repeating back a medication order to the provider.
d) A nurse checking the crash cart. ANS: c) A nurse repeating back a
medication order to the provider. Rationale: Closed-loop communication
involves repeating the message for confirmation and accuracy.
Fill-in-the-Blank
________ is the term used to describe secure, real-time, online communication
between nurses and other healthcare team members using electronic devices.
ANS: Telehealth
Rationale: Telehealth supports real-time secure communication in healthcare.
In clinical informatics, the process of translating clinical observations into
discrete codes or terminologies for electronic health records is known as
________.
ANS: Data standardization (or Clinical coding)
Rationale: Standardizing or coding data allows interoperability and analysis.
The federal law that mandates the protection of patient health information,
especially relevant in nursing documentation and informatics, is called
________.
ANS: HIPAA (Health Insurance Portability and Accountability Act)
Rationale: HIPAA ensures privacy and security of health information.
True/False
The use of structured hand-off tools, such as I-PASS and SBAR, has been
shown to decrease communication errors in nursing practice.
ANS: True
Rationale: Research supports structured hand-off tools improving
communication and reducing errors.
Nurses are not legally responsible for ensuring the accuracy of information
entered into the patient’s electronic health record (EHR).
ANS: False
Rationale: Nurses have legal and professional responsibilities for accurate
documentation.
Data encryption in nursing informatics helps to prevent unauthorized access to
patient health records transmitted over networks.
ANS: True
Rationale: Encryption protects data integrity and confidentiality during
transmission.
In clinical documentation, the terms “confidentiality” and “privacy” mean the
same thing and can be used interchangeably in nursing informatics.
ANS: False
Rationale: Confidentiality relates to information management/handling, while
privacy relates to an individual's right to control their data.
Multiple Response (Select ALL that apply)
13. Which of the following are benefits of using standardized nursing
terminologies (such as NANDA, NIC, NOC) in electronic health records?
a) Improves interoperability
b) Facilitates quality improvement
c) Ensures medication reconciliation
d) Supports nursing research ANS: a), b), d) Rationale: Standard terminologies
, promote interoperability, quality improvement, and research.
14. Which aspects are important for ensuring patient-centered communication
when using electronic documentation systems?
a) Ensuring eye contact during patient interviews
b) Verifying patient understanding before signing consents
c) Typing while speaking without clarifying information
d) Using lay language for explanations ANS: a), b), d) Rationale: Patient-
centered communication emphasizes nonverbal cues, understanding, and clear
language.
15. Which roles are associated with Nursing Informatics Specialists?
a) System implementation consultant
b) Health IT educator
c) Data analytics & outcomes manager
d) Primary case manager only ANS: a), b), c) Rationale: Informatics nurses
undertake many roles, except case management, which is not specifically
informatics-related.
Multiple Choice
16. A nurse is documenting a patient's update in a structured data field, rather
than a narrative note. The main advantage of structured fields is:
a) Easier to write lengthy notes
b) Enhances data retrieval and reporting
c) Allows for greater storytelling
d) Reduces legal accountability ANS: b) Enhances data retrieval and reporting
Rationale: Structured fields improve data searchability and analysis.
17. Which ethical principle is most at risk if a nurse discusses patient data on
social media platforms?
a) Autonomy
b) Beneficence
c) Confidentiality
d) Justice ANS: c) Confidentiality Rationale: Using social media risks patient
confidentiality.
18. Clinical decision support systems (CDSS) are designed primarily to:
a) Replace clinical judgment
b) Provide reminders or alerts to assist clinical decisions
c) Monitor staff workflow
d) Assign patient beds ANS: b) Provide reminders or alerts to assist clinical
decisions Rationale: CDSS supplements, but does not replace, clinician
decisions.
19. During an interprofessional team meeting, a nurse uses active listening
techniques. Which of the following is NOT part of active listening?
a) Making eye contact
b) Nodding and paraphrasing
c) Interrupting to correct minor details
d) Asking clarifying questions ANS: c) Interrupting to correct minor details
Rationale: Interrupting disrupts communication and is not part of active
listening.
20. A nurse realizes an error was made in an electronic record and corrects it
appropriately. This action demonstrates the legal requirement of:
a) Authentication
b) Audit trail
Nursing Communication &
Informatics
Final Exam Review
(With Solutions)
2025
Multiple Choice
A nurse is using SBAR (Situation, Background, Assessment, Recommendation)
to communicate a patient’s worsening condition to a physician. Which part of
SBAR ensures the nurse gives their clinical judgment about the problem?
a) Situation
b) Background
c) Assessment
d) Recommendation ANS: c) Assessment Rationale: Assessment involves the
nurse's evaluation or clinical judgment about the patient's problem.
Which of the following best describes the primary function of a Nursing
Information System (NIS) in a clinical setting?
a) Documenting patient billing information
b) Automating medication dispensing only
c) Supporting nursing documentation, care planning, and decision making
d) Managing environmental services ANS: c) Supporting nursing
documentation, care planning, and decision making Rationale: NIS are designed
to aid nurses in patient documentation, care planning, and clinical decision
support.
In a hospital using electronic health records (EHR), what communication
standard is commonly used to exchange health information between systems?
a) ISO 9001
b) HL7
c) HIPAA
d) COBIT ANS: b) HL7 Rationale: HL7 (Health Level Seven) is the
international standard for health information exchange.
During bedside shift report, a nurse asks the patient if they have any questions.
This demonstrates the communication principle of:
a) Filtering
b) Feedback
c) Encoding
d) Channeling ANS: b) Feedback Rationale: Seeking feedback ensures the
message has been understood and allows clarification.
Which of the following scenarios best demonstrates closed-loop communication
technique in nursing?
,a) A nurse giving instructions and assuming they were heard.
b) A nurse documenting patient history.
c) A nurse repeating back a medication order to the provider.
d) A nurse checking the crash cart. ANS: c) A nurse repeating back a
medication order to the provider. Rationale: Closed-loop communication
involves repeating the message for confirmation and accuracy.
Fill-in-the-Blank
________ is the term used to describe secure, real-time, online communication
between nurses and other healthcare team members using electronic devices.
ANS: Telehealth
Rationale: Telehealth supports real-time secure communication in healthcare.
In clinical informatics, the process of translating clinical observations into
discrete codes or terminologies for electronic health records is known as
________.
ANS: Data standardization (or Clinical coding)
Rationale: Standardizing or coding data allows interoperability and analysis.
The federal law that mandates the protection of patient health information,
especially relevant in nursing documentation and informatics, is called
________.
ANS: HIPAA (Health Insurance Portability and Accountability Act)
Rationale: HIPAA ensures privacy and security of health information.
True/False
The use of structured hand-off tools, such as I-PASS and SBAR, has been
shown to decrease communication errors in nursing practice.
ANS: True
Rationale: Research supports structured hand-off tools improving
communication and reducing errors.
Nurses are not legally responsible for ensuring the accuracy of information
entered into the patient’s electronic health record (EHR).
ANS: False
Rationale: Nurses have legal and professional responsibilities for accurate
documentation.
Data encryption in nursing informatics helps to prevent unauthorized access to
patient health records transmitted over networks.
ANS: True
Rationale: Encryption protects data integrity and confidentiality during
transmission.
In clinical documentation, the terms “confidentiality” and “privacy” mean the
same thing and can be used interchangeably in nursing informatics.
ANS: False
Rationale: Confidentiality relates to information management/handling, while
privacy relates to an individual's right to control their data.
Multiple Response (Select ALL that apply)
13. Which of the following are benefits of using standardized nursing
terminologies (such as NANDA, NIC, NOC) in electronic health records?
a) Improves interoperability
b) Facilitates quality improvement
c) Ensures medication reconciliation
d) Supports nursing research ANS: a), b), d) Rationale: Standard terminologies
, promote interoperability, quality improvement, and research.
14. Which aspects are important for ensuring patient-centered communication
when using electronic documentation systems?
a) Ensuring eye contact during patient interviews
b) Verifying patient understanding before signing consents
c) Typing while speaking without clarifying information
d) Using lay language for explanations ANS: a), b), d) Rationale: Patient-
centered communication emphasizes nonverbal cues, understanding, and clear
language.
15. Which roles are associated with Nursing Informatics Specialists?
a) System implementation consultant
b) Health IT educator
c) Data analytics & outcomes manager
d) Primary case manager only ANS: a), b), c) Rationale: Informatics nurses
undertake many roles, except case management, which is not specifically
informatics-related.
Multiple Choice
16. A nurse is documenting a patient's update in a structured data field, rather
than a narrative note. The main advantage of structured fields is:
a) Easier to write lengthy notes
b) Enhances data retrieval and reporting
c) Allows for greater storytelling
d) Reduces legal accountability ANS: b) Enhances data retrieval and reporting
Rationale: Structured fields improve data searchability and analysis.
17. Which ethical principle is most at risk if a nurse discusses patient data on
social media platforms?
a) Autonomy
b) Beneficence
c) Confidentiality
d) Justice ANS: c) Confidentiality Rationale: Using social media risks patient
confidentiality.
18. Clinical decision support systems (CDSS) are designed primarily to:
a) Replace clinical judgment
b) Provide reminders or alerts to assist clinical decisions
c) Monitor staff workflow
d) Assign patient beds ANS: b) Provide reminders or alerts to assist clinical
decisions Rationale: CDSS supplements, but does not replace, clinician
decisions.
19. During an interprofessional team meeting, a nurse uses active listening
techniques. Which of the following is NOT part of active listening?
a) Making eye contact
b) Nodding and paraphrasing
c) Interrupting to correct minor details
d) Asking clarifying questions ANS: c) Interrupting to correct minor details
Rationale: Interrupting disrupts communication and is not part of active
listening.
20. A nurse realizes an error was made in an electronic record and corrects it
appropriately. This action demonstrates the legal requirement of:
a) Authentication
b) Audit trail
