ATI: Engage Fundamentals RN2.0 – Documentation Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

ATI: Engage Fundamentals RN2.0 – Documentation Questions and Answers | Latest Version | 2025/2026 | Correct & Verified What is the appropriate method for correcting a documentation error in a paper chart? Draw a single line through the error, write "error," initial, and date it When should a nurse document care provided to a client? As soon as possible after providing care What should the nurse avoid including in client documentation? Personal opinions or judgments Which term is appropriate to use in client documentation? Client states “I feel dizzy” How should a nurse document a client refusal of medication? Client refused medication; educated on purpose and risks; provider notified 2 If a nurse delegates a task to a CNA, who is responsible for documenting the care? The person who performed the task What is the best way to document pain assessment? Client rates pain 7/10, sharp, located in lower back Why is it important to use only approved abbreviations in documentation? To prevent miscommunication and ensure clarity What should a nurse do if a client reports a new symptom during a shift? Document the symptom in detail and notify the provider How should a nurse document a wound dressing change? Dressing changed to right ankle wound; area clean, dry, no drainage; client tolerated procedure What is the purpose of using standardized flowsheets in electronic documentation? 3 To promote efficiency and consistency in charting How can a nurse ensure documentation meets legal and ethical standards? Record factual, accurate, complete, and timely information Why should a nurse avoid documenting in advance? Events may not occur as expected, and pre-charting is legally inaccurate What should a nurse document when administering a PRN medication? Medication name, dose, route, time given, reason, and client’s response How should a nurse document a fall incident? Client found on floor, alert, no visible injuries; provider notified; fall protocol initiated What is the best way to document