Free Documentation, Reporting and Communication MCQs with Answers
50 Documentation, Reporting and Communication MCQs from Fundamentals of Nursing, each with the correct answer and a written explanation of why it is correct. Free and unlimited, with no account needed.
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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50 questions · page 1 of 3
- A. Patient says, "I feel dizzy" after standing.
- B. Patient appears anxious and looks very unwell.
- C. Patient is difficult and refuses all treatment.
- D. Patient seems uncomfortable during the procedure.
Explanation: The statement in option A records the patient’s own words, making it subjective data documented accurately.
Correct answer: Patient says, "I feel dizzy" after standing.- A. Erase the error and write the correct entry.
- B. Cover the error with correction fluid and rewrite it.
- C. Draw one line through it, then sign and date it.
- D. Remove the page and complete a replacement page.
Explanation: A single line keeps the original entry readable, while the nurse adds the correction, date, time, and signature according to facility…
Correct answer: Draw one line through it, then sign and date it.- A. Complete an incident report before assessing the patient.
- B. Assess the patient and notify the prescriber promptly.
- C. Document that no harm occurred and continue the dose.
- D. Wait until the next shift to discuss the medication error.
Explanation: The patient’s immediate safety and assessment take priority after a medication error.
Correct answer: Assess the patient and notify the prescriber promptly.- A. It replaces the patient’s progress note about the event.
- B. It is used to record facts about an unusual event.
- C. It is placed in the patient’s medical record for review.
- D. It is completed only when the patient has an injury.
Explanation: An incident report records factual details of an unusual event, including events that cause no injury or near misses.
Correct answer: It is used to record facts about an unusual event.- A. The patient was admitted with pneumonia yesterday.
- B. The patient’s respiratory rate is 30 per minute and oxygen saturation is 88%.
- C. The patient needs review by the medical officer now.
- D. The patient has a history of chronic bronchitis.
Explanation: Assessment states the nurse’s current clinical findings and interpretation, such as abnormal respiratory rate and oxygen saturation.
Correct answer: The patient’s respiratory rate is 30 per minute and oxygen saturation is 88%.- A. Do not worry because the operation is routine.
- B. You sound frightened; what concerns you most?
- C. You should ask the surgeon about the operation.
- D. Many patients feel this way before surgery.
Explanation: This response acknowledges the patient’s emotion and uses an open question to encourage expression of concerns.
Correct answer: You sound frightened; what concerns you most?- A. Continue speaking quietly because no visitors are nearby.
- B. Discuss the results only with staff directly involved in care.
- C. Ask a relative to explain the results to the patient.
- D. Write the results on the ward noticeboard for the team.
Explanation: Confidential information should be shared only with healthcare professionals who need it for the patient’s care, using a private setting.
Correct answer: Discuss the results only with staff directly involved in care.- A. Patient fell because she is careless and confused.
- B. Patient found sitting on the floor beside the bed at 10:15 am.
- C. Patient had an accident and was probably frightened.
- D. Patient fell safely, so no further action was required.
Explanation: The entry records what the nurse observed, including the location and time, without assigning blame or guessing the cause.
Correct answer: Patient found sitting on the floor beside the bed at 10:15 am.- A. Accept the order and administer it without repeating it.
- B. Ask another nurse to remember the order for the next shift.
- C. Repeat the prescription back and record it according to policy.
- D. Wait for the prescriber to visit before recording the prescription.
Explanation: Read-back or repeat-back confirms that the prescription was heard correctly and reduces errors in names, doses, and routes.
Correct answer: Repeat the prescription back and record it according to policy.- A. Ask about the patient’s pain score before taking action.
- B. Check the patient immediately and call for urgent assistance.
- C. Complete the handover notes before visiting the patient.
- D. Offer oral fluids and reassess the patient after 30 minutes.
Explanation: Hypotension, pallor, and increasing drain output suggest possible postoperative haemorrhage, so circulation and immediate patient…
Correct answer: Check the patient immediately and call for urgent assistance.- A. Temperature is 38.4°C by oral thermometer
- B. Patient states, "My pain is 8 out of 10"
- C. Respiratory rate is 28 breaths per minute
- D. Skin is cool and clammy on examination
Explanation: Subjective data are symptoms or feelings reported by the patient, such as a pain score.
Correct answer: Patient states, "My pain is 8 out of 10"- A. Enter it in the earlier time slot without explanation
- B. Add a dated and timed late entry with the current time
- C. Ask another nurse to add the finding to the record
- D. Write it on a separate paper and keep it with the chart
Explanation: A late entry should be clearly labelled, dated and timed, and should state when the assessment actually occurred.
Correct answer: Add a dated and timed late entry with the current time- A. Medication given because it remains prescribed
- B. Medication refused, reason given, and prescriber informed
- C. Medication omitted without an entry to avoid blame
- D. Medication held and recorded as a medication error
Explanation: The nurse records the refusal, the patient’s stated reason when available, the assessment, and the actions taken, including notification…
Correct answer: Medication refused, reason given, and prescriber informed- A. Patient reports nausea after breakfast
- B. Blood pressure is 90/58 mmHg
- C. Nurse concludes that dehydration is suspected
- D. Encourage oral fluids as tolerated
Explanation: The assessment section contains the nurse’s clinical interpretation of the subjective and objective findings.
Correct answer: Nurse concludes that dehydration is suspected- A. Delete the entry and type a replacement
- B. Use the approved correction or addendum function
- C. Ask a colleague to change the entry under their login
- D. Leave the error because electronic records cannot be corrected
Explanation: The nurse should use the approved correction or addendum process so the original entry remains visible with an audit trail.
Correct answer: Use the approved correction or addendum function- A. The patient was admitted with pneumonia
- B. The patient has increasing work of breathing
- C. The oxygen saturation is 89% on 4 litres
- D. Please review the patient immediately and consider urgent treatment
Explanation: Recommendation states what action or response the nurse is requesting. The admission diagnosis is situation or background, the breathing…
Correct answer: Please review the patient immediately and consider urgent treatment- A. You should try to stay positive about the diagnosis
- B. Why are you refusing to talk about your illness?
- C. I notice this is difficult; what concerns you most now?
- D. Many patients feel this way, so there is no need to worry
Explanation: This response uses an observation and an open-ended, nonjudgmental question to invite the patient to share concerns.
Correct answer: I notice this is difficult; what concerns you most now?- A. Share only necessary information in a private setting
- B. Discuss the full history where visitors cannot hear clearly
- C. Send the record through a personal messaging application
- D. Leave the printed handover sheet at the nurses’ station
Explanation: Confidential communication uses the minimum information needed for care and occurs through an approved private channel.
Correct answer: Share only necessary information in a private setting- A. Record the report and reassess the patient at the next round
- B. Assess airway, breathing, circulation and immediate safety
- C. Ask the family to explain whether confusion is usual
- D. Complete routine documentation before seeing the patient
Explanation: Acute confusion may signal hypoxia, poor perfusion, hypoglycaemia or another urgent problem, so immediate assessment and safety take…
Correct answer: Assess airway, breathing, circulation and immediate safety- A. Tell the family because relatives should always be informed
- B. Promise that no healthcare worker will ever know
- C. Ask about the patient’s wishes and explain confidentiality limits
- D. Tell the family only if they call the nurses’ station repeatedly
Explanation: The nurse should explore the patient’s preference, protect privacy and explain that information is shared only with consent or when…
Correct answer: Ask about the patient’s wishes and explain confidentiality limitsDocumentation, Reporting and Communication MCQs: common questions
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