ATI engage fundamentals RN2.0 documentation questions and answers 2024/25

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include. - ANSWER Facilities can establish their own rules for documentation methods A staff nurse is evaluating a newly licensed nurse understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the informations? - ANSWER I can take a telephone prescription if a provider is directing a code for an unresponsive client A nurse is caring for a client following a stroke. The nurse should recongnized that which of the following individuals is allowed access to the client medical records without obtaining special consent form the client first - ANSWER 1. The admitting provider 2. The charge nurse on the unit 3. The client A nurse is discussing the history of electronic health records (EHR's) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs - ANSWER The Institute of Medicine A charge nurse is reviewing SOAP documentations with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective - ANSWER Rebound tenderness noted in RLQ of the abdomen A nurse is preparing to administer morphine 15 mg Po every 4hr PRN pain for a client who has a new prescription. By hich of the following routes should the nurse plan to administer the medication - ANSWER By mouth A nurse is preparing an in service about HIPAA. Which of the following information should the nurse plan to include - ANSWER Personnel can be terminated for breaching a clients confidentialiy A nurse is discussing com