NUR 209 EXAM 2 QUESTIONS WITH
100% CORRECT ANSWERS L LATEST
VERSION 2025/2026.
Communication with team - ANS Clear, accurate, up to date patient documentation is
cornerstone for safe delivery providing flow on info btw providers of care
- communicates plan of care and patient progress to all healthcare team members
- conveys clear picture of patient through diff viewpoints and at diff times
- ensures continuity of care and provides data for evaluation and revision or continuation of
care
Electronic Medical Record (EMR) characteristics - ANS Most clinical agencies have computer
used part or all of the patients record in an EHR. EHR provides a mean to collect and share
patient data electronically so it can be analyzed to improve outcomes. It allows for
standardization of documentation across healthcare team and to be viewed simultaneously
Documenting v Reporting - ANS Know the diff
Documenting - ANS handwritten, typed or electronic communication or documentation is a
form of written communication and serves as a permanent record of pt info and care provided
by all members of healthcare team
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Reporting - ANS Form of verbal communication and takes place when 2 or more people share
info about patient care
- face to face (team meeting, transfer of care, change of shift, handoff)
- telephone (reports to a case manager of provider from nurse making home visits )
objective data - ANS Observable and measurable pt data collected during physical
assessment
- observed through senses of sight, hearing, touch, smell
- Ex:
- BP 128/82 mm Hg
- pulse: 57 bpm
- skin pale and cool to touch
subjective data - ANS "S" for their "Symptoms"
Pts feelings about their health problems
- cannot be observed by nurse
Ex's:
- "I feel dizzy"
- "I have a sharp pain in my stomach"
Why do we document? What is the point? Why do we document immediately? - ANS Real
time documentation - take BP and document immediately
Why: accuracy and safety
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, When assessing a patient, how do we document current state? "Patient appears angry" but
OBJECTIVELY - ANS Using direct quotes of patient statements can help maintain objectivity
!!!!
→ actual pt behavior should be described rather than making interpretations!!!!
- avoid interpretations like "pt appears angry"
Ex:
" pt frowning , speaking loudly with arms crossed"
Don't label emotions- describe what you see and hear (tone, facial expression, posture)
Nurses role in verbal orders and how should nurse respond / action - ANS Face to face verbal
orders should only be given and taken in an EMERGENCY
- nurse check back by loudly and clearly repeating order
Telephone Orders - ANS Document call, write order and read back to provider over phone
- have 2 RN listening
SBAR - ANS Situation
Background
Assessment
Recommendation
Purpose of SBAR - ANS Report changes in patient status and may be used as a transfer of care
report
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
100% CORRECT ANSWERS L LATEST
VERSION 2025/2026.
Communication with team - ANS Clear, accurate, up to date patient documentation is
cornerstone for safe delivery providing flow on info btw providers of care
- communicates plan of care and patient progress to all healthcare team members
- conveys clear picture of patient through diff viewpoints and at diff times
- ensures continuity of care and provides data for evaluation and revision or continuation of
care
Electronic Medical Record (EMR) characteristics - ANS Most clinical agencies have computer
used part or all of the patients record in an EHR. EHR provides a mean to collect and share
patient data electronically so it can be analyzed to improve outcomes. It allows for
standardization of documentation across healthcare team and to be viewed simultaneously
Documenting v Reporting - ANS Know the diff
Documenting - ANS handwritten, typed or electronic communication or documentation is a
form of written communication and serves as a permanent record of pt info and care provided
by all members of healthcare team
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Reporting - ANS Form of verbal communication and takes place when 2 or more people share
info about patient care
- face to face (team meeting, transfer of care, change of shift, handoff)
- telephone (reports to a case manager of provider from nurse making home visits )
objective data - ANS Observable and measurable pt data collected during physical
assessment
- observed through senses of sight, hearing, touch, smell
- Ex:
- BP 128/82 mm Hg
- pulse: 57 bpm
- skin pale and cool to touch
subjective data - ANS "S" for their "Symptoms"
Pts feelings about their health problems
- cannot be observed by nurse
Ex's:
- "I feel dizzy"
- "I have a sharp pain in my stomach"
Why do we document? What is the point? Why do we document immediately? - ANS Real
time documentation - take BP and document immediately
Why: accuracy and safety
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, When assessing a patient, how do we document current state? "Patient appears angry" but
OBJECTIVELY - ANS Using direct quotes of patient statements can help maintain objectivity
!!!!
→ actual pt behavior should be described rather than making interpretations!!!!
- avoid interpretations like "pt appears angry"
Ex:
" pt frowning , speaking loudly with arms crossed"
Don't label emotions- describe what you see and hear (tone, facial expression, posture)
Nurses role in verbal orders and how should nurse respond / action - ANS Face to face verbal
orders should only be given and taken in an EMERGENCY
- nurse check back by loudly and clearly repeating order
Telephone Orders - ANS Document call, write order and read back to provider over phone
- have 2 RN listening
SBAR - ANS Situation
Background
Assessment
Recommendation
Purpose of SBAR - ANS Report changes in patient status and may be used as a transfer of care
report
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
