Documentation and Hand-Off Communication · NCLEX Exam

A nurse receives a hand‐off but notices the outgoing nurse leaves before allowing questions, and the incoming nurse cannot confirm key information. This violates which best practice principle?

  1. Wait until the next shift to record it for convenience.
  2. Document the change only if the physician orders it done.
  3. Record the change, action taken, and response, then notify the provider.
  4. Write 'see provider note' in the chart and move on to other tasks.
Show answer and explanation

Correct answer: Record the change, action taken, and response, then notify the provider.

Prompt documentation of status changes, the actions taken, and the patient's response is vital for accurate communication and continuity of care.

Difficulty: Medium Question 16 of 20

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