NMC Communication and Documentation 2 — Questions and Answers
Question 1: A patient with limited English proficiency requires discharge teaching. What is the most appropriate action?
- Ask a bilingual family member to translate
- Use a professional interpreter service (Correct answer)
- Speak slowly and use gestures only
- Postpone teaching until a bilingual nurse is available
Correct answer: Use a professional interpreter service
Professional interpreter services ensure accurate, confidential communication and are required by NMC standards when a language barrier exists.
Question 2: Which of the following best describes a SBAR communication tool?
- Subjective, Background, Assessment, Recommendation
- Situation, Background, Assessment, Recommendation (Correct answer)
- Situation, Brief, Action, Response
- Summary, Background, Action, Review
Correct answer: Situation, Background, Assessment, Recommendation
SBAR stands for Situation, Background, Assessment, Recommendation and is a structured handover tool endorsed by NMC.
Question 3: A nurse discovers a medication error was not documented by the previous shift. What should the nurse do?
- Document the error with today's date and time, noting it occurred during the previous shift (Correct answer)
- Leave it undocumented to protect the colleague
- Alter the previous shift's notes to include the error
- Verbally inform the ward manager only
Correct answer: Document the error with today's date and time, noting it occurred during the previous shift
Late entries must be recorded accurately with the actual time of the event and the time of documentation to maintain transparency.
Question 4: When is it appropriate for a nurse to break patient confidentiality without consent?
- When a curious colleague asks about the patient
- When there is a serious risk of harm to the patient or others (Correct answer)
- When the patient's family requests the information
- When the nurse feels it would help the patient's recovery
Correct answer: When there is a serious risk of harm to the patient or others
NMC Code permits disclosure without consent only when there is a serious, credible risk of harm to the patient or a third party.
Question 5: A patient refuses to have their care discussed in front of a student nurse. The nurse should:
- Insist the student must stay for learning purposes
- Respect the patient's decision and ask the student to leave (Correct answer)
- Ignore the request as students are part of the team
- Document the refusal and continue the discussion anyway
Correct answer: Respect the patient's decision and ask the student to leave
Patients have the right to control who is present during their care discussions; respecting this upholds dignity and the NMC Code.
Question 6: Which statement about electronic nursing records is most accurate?
- Electronic records do not need to meet the same standards as paper records
- Electronic records must be accurate, legible, and only altered by authorized personnel (Correct answer)
- Any healthcare worker can edit electronic records at any time
- Electronic records are automatically updated and require no nurse input
Correct answer: Electronic records must be accurate, legible, and only altered by authorized personnel
NMC standards apply equally to electronic records; they must be accurate, and entries should only be made or amended by authorized individuals with audit trails.
Question 7: During a clinical handover, the oncoming nurse should:
- Accept all information passively without questioning
- Read the notes independently without verbal handover
- Actively clarify any unclear or incomplete information received (Correct answer)
- Hand over only critical patients to save time
Correct answer: Actively clarify any unclear or incomplete information received
Active clarification during handover is essential to patient safety and is a core NMC expectation for effective communication.
NMC Communication and Documentation 2
A patient with limited English proficiency requires discharge teaching.
What is the most appropriate action?