ATI Documentation Complete Review: Essential
Nursing Charting Skills, Accurate Patient Records,
Legal Responsibilities, and Professional
Communication Strategies
Question 1
A nurse is documenting in a client's electronic health record. Which of the
following entries is an example of correct documentation?
A. "Client appears anxious and restless"
B. "Client is having a bad day"
C. "Client seems upset about diagnosis"
D. "Client reports feeling anxious, states heart is racing"
Answer: D
Rationale: Documentation must be objective, factual, and use the client's own
words when reporting subjective data. Option D correctly documents the client's
direct quote and specific symptoms. Options A, B, and C are subjective
interpretations and opinions, which are not appropriate for medical records.
Question 2
A nurse is completing an incident report after a client falls. Which action by the
nurse is appropriate?
A. Document the fall in the client's medical record and note that an incident
report was filed
B. Place the incident report in the client's medical record
C. Document "incident report filed" in the client's chart only
D. Make a copy of the incident report for the client's family
Answer: A
Rationale: The nurse should document the facts of the incident in the client's
medical record and note that an incident report was completed. Incident reports
are confidential risk-management documents and should never be placed in the
,client's medical record, copied for family, or used as a substitute for proper
documentation.
Question 3
A nurse is preparing to obtain informed consent from a client for a surgical
procedure. Which of the following is the nurse's responsibility?
A. Explain the risks and benefits of the procedure
B. Witness the client's signature on the consent form
C. Determine if the client is mentally competent
D. Perform the surgical procedure
Answer: B
Rationale: The nurse's role in informed consent is to witness the client's
signature and ensure the consent form is signed voluntarily. The provider
(physician or surgeon) is responsible for explaining the risks, benefits, and
alternatives. Determining competency is a legal/medical determination made by
the provider, not the nurse.
Question 4
A nurse is documenting a client's blood pressure reading of 142/88 mmHg. Which
of the following is the correct way to document this finding?
A. BP elevated
B. BP 142/88
C. Client's BP is high
D. BP slightly above normal
Answer: B
Rationale: Documentation must be precise, objective, and factual. Recording the
exact numerical value (BP 142/88) is the correct practice. Subjective or vague
descriptions such as "elevated," "high," or "slightly above normal" are
inappropriate for medical records.
,Question 5
A nurse is caring for a client who refuses a prescribed medication. What is the
appropriate nursing action?
A. Administer the medication anyway
B. Document the refusal and notify the provider
C. Hide the medication in the client's food
D. Tell the client they cannot refuse treatment
Answer: B
Rationale: Clients have the right to refuse treatment. The nurse should document
the refusal, including the time, the client's reason (if stated), and the provider
notified. The medication should not be administered, coerced, or hidden.
Question 6
A nurse is documenting care provided to a client. Which of the following
abbreviations is acceptable to use?
A. QD
B. U
C. IU
D. mg
Answer: D
Rationale: "mg" (milligram) is an acceptable abbreviation. "QD" (daily), "U" (unit),
and "IU" (international unit) are on the Joint Commission's "Do Not Use" list due
to high risk of misinterpretation and medication errors.
Question 7
A nurse overhears two colleagues discussing a client's diagnosis in the hospital
elevator. Which action should the nurse take?
A. Join the conversation
B. Ignore the conversation
, C. Remind the colleagues that this is a violation of HIPAA
D. Report the colleagues to the police
Answer: C
Rationale: Discussing client information in a public area (elevator) is a violation of
HIPAA and client confidentiality. The nurse has a duty to remind colleagues of
confidentiality requirements. Reporting to police is excessive; the nurse can later
report to a supervisor if needed.
Question 8
A nurse is preparing to document a client's response to pain medication. Which of
the following is the most appropriate documentation?
A. "Client appears comfortable"
B. "Client sleeping, appears pain-free"
C. "Client reports pain decreased from 8/10 to 3/10 30 minutes after morphine 4
mg IV"
D. "Client no longer complaining of pain"
Answer: C
Rationale: This documentation is specific, objective, and includes measurable
data: pain scale rating, time, medication, dose, and route. Options A, B, and D are
subjective interpretations.
Question 9
A nurse is caring for a client who has a living will. Which statement by the nurse
demonstrates understanding of advance directives?
A. "The living will takes effect when the client is admitted to the hospital"
B. "The living will guides treatment decisions if the client cannot communicate"
C. "The family can override the living will at any time"
D. "The living will only applies to surgical procedures"
Answer: B
Nursing Charting Skills, Accurate Patient Records,
Legal Responsibilities, and Professional
Communication Strategies
Question 1
A nurse is documenting in a client's electronic health record. Which of the
following entries is an example of correct documentation?
A. "Client appears anxious and restless"
B. "Client is having a bad day"
C. "Client seems upset about diagnosis"
D. "Client reports feeling anxious, states heart is racing"
Answer: D
Rationale: Documentation must be objective, factual, and use the client's own
words when reporting subjective data. Option D correctly documents the client's
direct quote and specific symptoms. Options A, B, and C are subjective
interpretations and opinions, which are not appropriate for medical records.
Question 2
A nurse is completing an incident report after a client falls. Which action by the
nurse is appropriate?
A. Document the fall in the client's medical record and note that an incident
report was filed
B. Place the incident report in the client's medical record
C. Document "incident report filed" in the client's chart only
D. Make a copy of the incident report for the client's family
Answer: A
Rationale: The nurse should document the facts of the incident in the client's
medical record and note that an incident report was completed. Incident reports
are confidential risk-management documents and should never be placed in the
,client's medical record, copied for family, or used as a substitute for proper
documentation.
Question 3
A nurse is preparing to obtain informed consent from a client for a surgical
procedure. Which of the following is the nurse's responsibility?
A. Explain the risks and benefits of the procedure
B. Witness the client's signature on the consent form
C. Determine if the client is mentally competent
D. Perform the surgical procedure
Answer: B
Rationale: The nurse's role in informed consent is to witness the client's
signature and ensure the consent form is signed voluntarily. The provider
(physician or surgeon) is responsible for explaining the risks, benefits, and
alternatives. Determining competency is a legal/medical determination made by
the provider, not the nurse.
Question 4
A nurse is documenting a client's blood pressure reading of 142/88 mmHg. Which
of the following is the correct way to document this finding?
A. BP elevated
B. BP 142/88
C. Client's BP is high
D. BP slightly above normal
Answer: B
Rationale: Documentation must be precise, objective, and factual. Recording the
exact numerical value (BP 142/88) is the correct practice. Subjective or vague
descriptions such as "elevated," "high," or "slightly above normal" are
inappropriate for medical records.
,Question 5
A nurse is caring for a client who refuses a prescribed medication. What is the
appropriate nursing action?
A. Administer the medication anyway
B. Document the refusal and notify the provider
C. Hide the medication in the client's food
D. Tell the client they cannot refuse treatment
Answer: B
Rationale: Clients have the right to refuse treatment. The nurse should document
the refusal, including the time, the client's reason (if stated), and the provider
notified. The medication should not be administered, coerced, or hidden.
Question 6
A nurse is documenting care provided to a client. Which of the following
abbreviations is acceptable to use?
A. QD
B. U
C. IU
D. mg
Answer: D
Rationale: "mg" (milligram) is an acceptable abbreviation. "QD" (daily), "U" (unit),
and "IU" (international unit) are on the Joint Commission's "Do Not Use" list due
to high risk of misinterpretation and medication errors.
Question 7
A nurse overhears two colleagues discussing a client's diagnosis in the hospital
elevator. Which action should the nurse take?
A. Join the conversation
B. Ignore the conversation
, C. Remind the colleagues that this is a violation of HIPAA
D. Report the colleagues to the police
Answer: C
Rationale: Discussing client information in a public area (elevator) is a violation of
HIPAA and client confidentiality. The nurse has a duty to remind colleagues of
confidentiality requirements. Reporting to police is excessive; the nurse can later
report to a supervisor if needed.
Question 8
A nurse is preparing to document a client's response to pain medication. Which of
the following is the most appropriate documentation?
A. "Client appears comfortable"
B. "Client sleeping, appears pain-free"
C. "Client reports pain decreased from 8/10 to 3/10 30 minutes after morphine 4
mg IV"
D. "Client no longer complaining of pain"
Answer: C
Rationale: This documentation is specific, objective, and includes measurable
data: pain scale rating, time, medication, dose, and route. Options A, B, and D are
subjective interpretations.
Question 9
A nurse is caring for a client who has a living will. Which statement by the nurse
demonstrates understanding of advance directives?
A. "The living will takes effect when the client is admitted to the hospital"
B. "The living will guides treatment decisions if the client cannot communicate"
C. "The family can override the living will at any time"
D. "The living will only applies to surgical procedures"
Answer: B
