Study Guide DRAFT Newest 2026 Questions and
Correct Detailed Answers Already Graded A+
-Situation --> What is happening at the current time? What is the important
problem? (provide a brief description of patient variables, demographics,
diagnosis, and location)
-Background --> What are the circumstances that lead to this situation? What
subjective and objective data do you have that is important for the receiver to
know? (provide history as it is related to patient's current health)
-Assessment --> What do you think is happening? (state interpretation of
assessment data)
-Recommendation/Request --> What do you think needs to be done? (state what
you need for patient in terms of treatment or assistance) - CORRECT ANSWER-
What is SBAR?
-Requisition
-Patient's name and ID # (MRN)
-Patient's DOB
,-Date and time of collection
-Initials of person who collected
-Time of collection
-Transport in biohazard bag
-Complete at bedside to ensure right patient*** - CORRECT ANSWER-What is
included in a correct labeling of a specimen collection?
-pH --> indicates acid-base balance
-Protein levels --> indicates kidney function
-Glucose --> diabetes
-Ketones --> indicates dehydration, starvation, excessive aspirin intake, and poor
diabetes control
-Specific gravity --> indicates concentration of particles
-RBCs --> indicates trauma or disease
-WBCs --> indicates inflammation or infection
-Bacteria --> indicates infection
-Crystals --> at risk for kidney stones
-Cultures are not a part of a routine UA - CORRECT ANSWER-What does a
routine urinalysis (UA) include, and what does each component indicate?
,Subjective data --> what the patient says
Objective data --> what you observe, such as VS, lab results, and physical
assessment findings
Assessment --> interpret the subjective and objective data and state the problem
or note client progress on the problem (may be in the form of a nursing diagnosis)
-Plan --> plan of care to address the problem - CORRECT ANSWER-What is
SOAP charting?
Format: (Prohibited abbreviation ) = (Correct term)
-U = unit
-IU = International Unit
-Q.D. (QD, qd, q.d.), Q.O.D. (QOD), qod, q.o.d.) = daily, every other day
-Trailing zero (X.0 mg) = never write a zero by itself after decimal point (X mg)
-Lack of leading zero (.X mg) = always use a zero before a decimal point (0.X mg)
-MS, MSO4, MgSO4 = morphine or magnesium sulfate
-µg = mcg or microgram
-cc = ml for milliliters
-AS, AD, AU, OS, OD, OU = left ear, right ear, both ears, left eye, right eye, both
eyes
, -Ambivalent duration (such as bid x 10d) = "doses" or "days"
-SQ, SC = write "Sub-Q" or "subcutaneously" - CORRECT ANSWER-What are
prohibited abbreviations, and what are the corrections?
Narrative charting is used to tell a story and has several standardized formats,
including SOAP. Narrative notes are useful in any situation where something
unusual/unexpected happens or when you need to communicate with a provider.
- CORRECT ANSWER-When is a narrative note useful?
Leaking any of the following:
-Names (full or last name and initial)
-All geographical identifiers smaller than a state
-Dates (other than year) directly related to an individual
-Phone numbers
-Fax numbers
-Email address
-SSN
-MRN
-Health insurance beneficiary numbers