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 3 of 3
- A. The response of the patient to care
- B. The reason for the patient’s admission
- C. The record of the patient’s diagnosis
- D. The referral made to another department
Explanation: In DAR charting, D means data, A means action, and R means the patient’s response.
Correct answer: The response of the patient to care- A. Recount the medication with another authorised nurse
- B. Change the previous entry to match the remaining stock
- C. Wait until the next shift to investigate the difference
- D. Remove the remaining medication from the treatment room
Explanation: The nurse should immediately perform a witnessed recount and compare the register with the medication administration records.
Correct answer: Recount the medication with another authorised nurse- A. The patient was admitted with pneumonia two days ago
- B. The patient’s oxygen saturation is 88 percent
- C. The patient needs urgent review by the medical officer
- D. The patient is becoming increasingly breathless
Explanation: Background includes relevant history, diagnosis, treatment, and events leading to the current problem.
Correct answer: The patient was admitted with pneumonia two days ago- A. Adding the date, time, signature, and professional designation
- B. Writing the entry at the end of the shift without a time
- C. Using the initials of another nurse who witnessed the care
- D. Leaving space so another nurse can add further information
Explanation: A nursing entry should identify when the care occurred and who documented it, including the nurse’s signature and professional…
Correct answer: Adding the date, time, signature, and professional designation- A. The patient correctly demonstrates the steps and explains when to use it
- B. The patient receives written instructions about the peak-flow meter
- C. The nurse explains the procedure slowly and answers questions
- D. The patient says that the instructions appear easy to understand
Explanation: Return demonstration and patient explanation provide evidence that the patient can perform and understand the skill.
Correct answer: The patient correctly demonstrates the steps and explains when to use it- A. Remain quietly present and allow the patient time to respond
- B. Change the subject to avoid increasing the patient’s distress
- C. Ask several rapid questions to identify the main problem
- D. Tell the patient that remaining positive will make coping easier
Explanation: Therapeutic silence allows the patient time to process feelings and communicate at their own pace.
Correct answer: Remain quietly present and allow the patient time to respond- A. Report the result promptly using a clear, structured message
- B. Record the result and wait for the next routine ward round
- C. Ask the patient’s relative whether the result seems concerning
- D. Send the result to an unrelated ward for a second opinion
Explanation: A dangerously low potassium level can cause serious cardiac dysrhythmias, so it requires prompt reporting to the responsible clinician.
Correct answer: Report the result promptly using a clear, structured message- A. Use an approved trained interpreter for accurate communication
- B. Ask a young family member to translate the clinical questions
- C. Speak much louder and repeat the same English words
- D. Use gestures alone to determine the severity of the pain
Explanation: A trained interpreter improves accuracy, privacy, and informed decision-making.
Correct answer: Use an approved trained interpreter for accurate communication- A. Clarify the allergy and record the verified information
- B. Assume the allergy is to the most common antibiotic
- C. Leave the allergy field blank until the next ward round
- D. Ask the patient to receive the medication and observe closely
Explanation: Unclear allergy information creates an immediate medication safety risk, so the nurse must clarify and verify it before treatment.
Correct answer: Clarify the allergy and record the verified information- A. A private clinical area where unauthorised people cannot hear
- B. The public corridor outside the patient’s room
- C. The hospital cafeteria during the meal break
- D. The lift while travelling to another floor
Explanation: Clinical handover should occur in a private area or at the bedside using an appropriate confidential approach.
Correct answer: A private clinical area where unauthorised people cannot hear