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 2 of 3
- A. The patient’s response and discharge plan
- B. The drug, dose, route, time and nurse’s initials
- C. The patient’s diagnosis and dietary preference
- D. The prescriber’s full progress note and treatment goals
Explanation: The medication administration record confirms what medication was given, in which dose and route, at what time, and by whom.
Correct answer: The drug, dose, route, time and nurse’s initials- A. Record the medication as given at the scheduled time
- B. Leave the medication record blank without further action
- C. Record that it was withheld, state the reason and follow policy
- D. Ask another nurse to sign for the medication instead
Explanation: The nurse should accurately record that the medication was not administered and document the reason, following local policy for…
Correct answer: Record that it was withheld, state the reason and follow policy- A. Are you feeling better today?
- B. You are not having pain, are you?
- C. Can you tell me what has been troubling you?
- D. Did the pain begin after you ate breakfast?
Explanation: An open-ended question allows the patient to describe concerns in their own words and supports therapeutic listening.
Correct answer: Can you tell me what has been troubling you?- A. You must remain calm because delays happen
- B. There is no reason to be angry at the nursing staff
- C. I can see that the long wait has been frustrating for you
- D. You should discuss the delay with the doctor later
Explanation: This response acknowledges the patient’s emotion without arguing or making promises.
Correct answer: I can see that the long wait has been frustrating for you- A. Filtering
- B. Feedback
- C. Defensive communication
- D. Nonverbal reassurance
Explanation: Feedback confirms that the message was received and understood accurately, which reduces communication errors during handover.
Correct answer: Feedback- A. Document the findings at the end of the shift
- B. Offer oral fluids and ask the patient to rest
- C. Report the acute findings immediately according to emergency policy
- D. Wait for the next routine medical round before reporting
Explanation: Sudden facial drooping and arm weakness may indicate an acute stroke and require immediate reporting for time-sensitive assessment and…
Correct answer: Report the acute findings immediately according to emergency policy- A. Recording care before it is performed
- B. Using vague terms such as patient seems fine
- C. Documenting assessments and interventions at the time they occur
- D. Allowing a colleague to sign an entry made by another nurse
Explanation: Timely documentation provides a reliable record of the patient’s condition and the care delivered.
Correct answer: Documenting assessments and interventions at the time they occur- A. Patient is uncomfortable
- B. Patient has severe pain
- C. Patient reports pain of 7 out of 10 in the lower abdomen
- D. Patient appears to have a pain problem
Explanation: The numerical rating and specific location communicate measurable information that another nurse can reassess.
Correct answer: Patient reports pain of 7 out of 10 in the lower abdomen- A. The patient’s preferred television programme
- B. The patient’s current abnormal assessment findings
- C. The patient’s complete social history from admission
- D. The patient’s planned discharge teaching topics
Explanation: Current abnormal findings are the most relevant information for immediate clinical decision-making and patient safety.
Correct answer: The patient’s current abnormal assessment findings- A. Give an uncertain answer to avoid delaying the patient
- B. Change the subject until the patient stops asking
- C. State that you will verify the information and return with an answer
- D. Tell the patient to search for the answer on the internet
Explanation: The nurse should be honest, seek accurate information from an appropriate source, and follow up with the patient.
Correct answer: State that you will verify the information and return with an answer- A. The patient problem identified
- B. The nursing intervention provided
- C. The evaluation of the response
- D. The equipment used during care
Explanation: In PIE charting, E means evaluation of the patient’s response to the intervention.
Correct answer: The evaluation of the response- A. Recording care before it is provided
- B. Charting as soon as possible after care
- C. Waiting until the end of the week
- D. Copying the previous shift’s complete note
Explanation: Charting soon after care improves accuracy and reduces forgotten details.
Correct answer: Charting as soon as possible after care- A. To record repeated observations efficiently
- B. To replace all narrative nursing notes
- C. To document only unexpected emergencies
- D. To record the prescriber’s treatment decisions
Explanation: A flow sheet provides an organized way to record repeated measurements and routine observations.
Correct answer: To record repeated observations efficiently- A. Ask an adult relative to explain the procedure
- B. Use a qualified medical interpreter
- C. Ask the patient to sign without further discussion
- D. Give the patient written information in English
Explanation: A qualified medical interpreter supports accurate understanding and voluntary consent.
Correct answer: Use a qualified medical interpreter- A. Insulin teaching completed
- B. Patient received routine education
- C. Patient correctly demonstrates the injection technique
- D. Patient was given an insulin information leaflet
Explanation: A return demonstration provides direct evidence that the patient can perform the skill safely.
Correct answer: Patient correctly demonstrates the injection technique- A. Copy the statement again for consistency
- B. Delete the earlier nurse’s original entry
- C. Assess the patient and document verified findings
- D. Ignore the statement because it is already recorded
Explanation: The nurse should assess the patient and record only current findings that can be verified.
Correct answer: Assess the patient and document verified findings- A. You should not worry about this problem
- B. I understand exactly how you feel
- C. You are saying that the pain worsens at night
- D. Why did you wait so long to tell me?
Explanation: Restating the patient’s message confirms understanding without judging or giving false reassurance.
Correct answer: You are saying that the pain worsens at night- A. Give a long chronological account of the admission
- B. State the current concern, findings, and requested review
- C. Wait until the next routine handover to mention it
- D. Ask another patient whether similar pain is expected
Explanation: An urgent report should focus on the present concern, relevant assessment findings, and the action needed.
Correct answer: State the current concern, findings, and requested review- A. The nurse’s personal opinion about the family
- B. The exact time, caller identity, message, and action taken
- C. A general statement that the family was difficult
- D. Only the fact that a telephone call occurred
Explanation: A complete telephone note identifies when the call occurred, who called, what was communicated, and what follow-up occurred.
Correct answer: The exact time, caller identity, message, and action taken- A. Join the discussion if the information is clinically interesting
- B. Silently leave and discuss it with friends later
- C. Ask the colleague to stop and move the discussion to a private area
- D. Record the conversation in the patient’s nursing notes
Explanation: Patient information should be discussed only with people who need it for care and in a private setting.
Correct answer: Ask the colleague to stop and move the discussion to a private area