NCLEX CRUSADE ACADEMY TEST - 6 TYPES OF NURSING REPORT

1. The formal mechanism for passing professional responsibility between nurses is known as: Documentation. Reporting. Delegation. Consultation.

2. A Change-of-Shift report primarily ensures: Legal defense. Equipment tracking. Continuity for the incoming nurse. Risk management only.

3. Telephone reports are primarily used for: Shift change only. Remote updates to providers. Legal incident documentation. Family teaching.

4. Transfer reports are required when: A patient is stable. Moving between units or facilities. Filing an incident report. Chart auditing.

5. SBAR stands for: Situation, Background, Action, Review. Status, Baseline, Analysis, Recommendation. Situation, Background, Assessment, Recommendation. Summary, Brief, Action, Report.

6. The 'S' in SBAR refers to: Summary. Situation (what is happening now). Safety. Status change.

7. The 'A' in SBAR represents: Action. Assessment (data collection and problem identification). Authorization. Agreement.

8. A complete clinical report must include patient: Insurance number only. Identity including name and room. Family contacts only. Social media history.

9. Current status refers to: Diagnosis only. Stable vs deteriorating condition now. Long-term history. Insurance authorization.

10. Logistics include: Patient opinions. Lab results and infusion status. Social history only. Physician salary.

11. Safety filters require inclusion of: Billing codes. Language barriers and safety risks. Hospital profit data. Legal statutes.

12. Family dynamics should be reported because: It improves billing. It reflects understanding of treatment. It replaces clinical data. It satisfies risk management only.

13. The primary purpose of an incident report is: Routine charting. Legal evidence and risk management. SBAR communication. Patient education.

14. Equipment failure must trigger: Shift report only. Incident report. Telephone report only. Discharge planning.

15. An incident involving a visitor must: Be ignored. Be documented in SBAR only. Also be reported. Be handled by family.

16. The golden rule of incident documentation is to document: Assumptions. Conclusions. Only observed facts. Speculation.

17. Writing 'Patient fell out of bed' when unwitnessed is: Objective documentation. Assumption. Required wording. SBAR format.

18. Correct language for unwitnessed fall is: Patient slipped. Patient found on floor. Patient fainted. Patient lost balance.

19. Incident reports must include: Diagnosis and care plan. Witnesses and equipment IDs. Insurance data. SBAR format.

20. Patient complaints should be documented using: Interpretation. Summary. Direct quotation. Diagnosis.

21. An incident report is: Part of the patient chart. Uploaded to EMR. Separate from the medical record. Documented in nursing notes.

22. Mentioning in chart that 'an incident report was filed' is: Required. Encouraged. Prohibited. Optional.

23. Routine reports focus on: Legal defense. Continuity of clinical care. Risk manager. Visitor injuries.

24. Incident reports are sent to: Next nurse. Provider. Risk manager. Patient family.

25. SBAR must be used for: Incident reports. Only shift change. Shift, phone, and transfer reports. Legal depositions.

26. The cardinal sin in documentation is: Missing vitals. Filing incident report in medical chart. Using SBAR. Quoting patient.

27. Documentation is considered your defense because: It increases revenue. It replaces assessment. It serves as written evidence. It avoids patient care.