Final Exam NURS 3205 TTU 2nd Degree Bootcamp
questions with correct answers
SBAR - What do the letters stand for? Correct Answer-S - Situation
B - Background
A - Assessment
R - Recommendation & Request
SBAR - Definition Correct Answer-PowerPoint - A technique for
communicating critical information among members of the team. This
may be used in a shift report situation. Or, it is useful for communication
when attention and action concerning a patient's condition are pertinent.
Textbook - Standardizes telephone communication of significant events
or changes in a patient's condition and is a communication strategy
designed to improve patient safety.
SBAR - Situation Correct Answer-PowerPoint - What is going on with
the patient? "I am calling about Mrs. Joseph in room 251. Chief
complaint is shortness of breath of new onset."
Textbook - When describing the situation you include both the admitting
and secondary diagnoses and the problem your patient is having as the
current issue.
SBAR - Background Correct Answer-PowerPoint - What is the clinical
background or context? "Patient is a 62 y/o female post-op day one from
abdominal surgery. No prior history of cardiac or lung disease."
,Textbook - Information includes pertinent medical history, previous
laboratory tests and treatments, psychosocial issues, allergies, and
current code status.
SBAR - Assessment Correct Answer-PowerPoint - What do I think the
problem is? "Breath sounds are decreased on the right side with
acknowledgement of pain. Would like to rule-out pneumothorax."
Textbook - Includes significant findings in your head-to-toe physical
assessment, recent vital signs, current treatment measures, restrictions,
recent laboratory results and diagnostics, and pain status.
SBAR - Recommendation & Request Correct Answer-PowerPoint -
What would I do to correct it? "I feel strongly the patient should be
assessed now. Are you available to come in?
Textbook - Suggest a plan of care and what needs to be addressed.
Documentation Correct Answer-Nursing documentation is a reflection
of nursing care provided. It can be written or electronic depending on the
facility. Charting should reflect the patient's journey (status and care) in
an accessible manner.
What are the 5 characteristics of nursing documentation? Correct
Answer-1) factual
2) accurate
3) complete
4) current
5) organized
, Joint Commission Correct Answer-sets guidelines for documentation.
Any agency's policies and procedures should align with their guidelines.
What is the Joint Commission's policy on making corrections in patient
charts? Correct Answer-- Draw a single line through an error
- Write "error", and initial and date.
- DO NOT use white out, scratch out, or erase
What should documentation in a patient's chart look like according to the
Joint Commission? Correct Answer-- In black ink
- Written legibly
According to the Joint Commission, documentation in a patient's chart
should be... Correct Answer-- Factual
- Objective
The Joint Commission says all entries in a patient's chart should include
what items? Correct Answer-- Date
- Signature
- Time
What should you NEVER include in your documentation according to
the Joint Commission? Correct Answer-- Opinions or assumptions
- Vague & generalized statements (ex: "Patient had a good day"
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