ATI: Engage Fundamentals: Professional Nursing: Documentation Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

ATI: Engage Fundamentals: Professional Nursing: Documentation Questions and Answers | Latest Version | 2025/2026 | Correct & Verified What is the nurse's legal responsibility regarding client documentation? Ensure entries are accurate, timely, and complete What type of documentation should include the time, date, and signature? All nursing notes and chart entries Why is it inappropriate to document a procedure before it has been performed? Because documentation must reflect actual events, not anticipated actions How should a nurse document client education provided? Include what was taught, the client’s response, and any materials given How should a nurse document a client's pain report? Record the client’s exact words, location, intensity, and any actions taken 2 What is a late entry in documentation? An entry added after the original time of care, labeled as “Late Entry” with the correct date and time Why should a nurse avoid documenting retaliatory or emotional statements? Because they are unprofessional and may be legally damaging When should a nurse document client care during a shift? As soon as possible after the care is provided What should a nurse include when documenting a dressing change? Wound appearance, type of dressing used, technique, and client response What is one consequence of incomplete or inaccurate documentation? Compromised client safety and potential legal liability What is the best way for a nurse to correct a documentation error in a paper chart? 3 Draw a single line through the error, write "error," initial and date it What should a nurse do immediately after completing a client intervention? Document the care provided in the client’s medical record Why is timely documentation important in nursing practice? It ensures continuity of care and supports accurate communication among healthcare team members What type of information is “Client states, ‘I feel dizzy’”? Subjective data What type of data is “Blood pressure 148/92 mm Hg”? Objective data What is the primary purpose of documentation in nursing? To communicate client status and care provided to the healthcare team 4 What should a nurse do before leaving a workstation after using an electronic health record? Log out of the system to protect client privacy What is the correct way to chart that a client refused medication? "Client refused medication, stating, ‘I do not want to take this pill right now.’" Why should a nurse avoid using vague terms like “good,” “okay,” or “normal” in documentation? Because they are not specific and may be interpreted