ATI DOCUMENTATION FINAL
EXAM UPDATE THIS YEAR
QUESTIONA newly licensed nurse is orienting to a facility's
documentation system. The facility requires staff to only
document variations form an expected set of findings when
performing a physical assessment. The nurse should identify this
system as which of the following documentation methods?
A. Charting by exception.
B. Subjective, objective, assessment, plan format.
C. Problem, intervention, evaluation model.
D. Data, action, response charting. - answer-A. Charting by
exception.
QUESTIONA nurse is discussing problem-oriented medical
records with a group of newly licensed nurses. Which of the
following information should the nurse include?
A. A problem-oriented medical record is created using the PIE
model for documentation entries.
B. A problem-oriented medical record contains seperate sections
for laboratory and diagnostic information.
C. A problem-oriented medical record promotes information
sharing among members of the interdisciplinary team.
D. A problem-oriented medical record is rarely used in acute care
settings. - answer-C. A problem-oriented medical record promotes
information sharing among members of the interdisciplinary team.
QUESTIONA nurse is discussing the history of electronic health
records (EHRs) during a staff in-service. The nurse should identify
that which fo the following agencies advocated for nationwide use
of EHRs?
A. The Institute of Medicine.
, B. Department of Veteran Affairs.
C. American Hospital Association.
D. The Joint Commission. - answer-A. The Institute of Medicine.
QUESTIONA nurse is preparing to administer morphine 15 mg
PO every 4 hr PRN pain for a client who has a new prescription.
By which of the following routes should the nurse plan to
administer the medication?
A. By mouth
B. Intramuscularly
C. Per rectum
D. Intravenously - answer-A. By mouth
A staff nurse if evaluating a newly licensed nurse's understanding
of telephone prescriptions. Which of the following statements by
the newly licensed nurse indicates an understanding of the
information?
A. "I can take a telephone prescription if a provider is making
routine rounds in another area of the facility."
B. "I can take a telephone prescription if a provider is directing a
code for an unresponsive client."
C. "If a client requires an over-the-counter medicatoin for relief of
nausea, it is okay to accept a telephone prescription."
D. "If a client requires pain control for a terminal condition, it is
okay to accept a telephone prescription." - answer-B. "I can take a
telephone prescription if a provider is directing a code for an
unresponsive client."
QUESTIONA nurse is caring for a client following a stroke. The
nurse should recognize that which of the following individuals is
allowed access to the client's medical record without obtaining
special consent form the client first? (Select all that apply)
A. The admitting provider.
B. The charge nurse of the unit.
C. The client's sibling.
EXAM UPDATE THIS YEAR
QUESTIONA newly licensed nurse is orienting to a facility's
documentation system. The facility requires staff to only
document variations form an expected set of findings when
performing a physical assessment. The nurse should identify this
system as which of the following documentation methods?
A. Charting by exception.
B. Subjective, objective, assessment, plan format.
C. Problem, intervention, evaluation model.
D. Data, action, response charting. - answer-A. Charting by
exception.
QUESTIONA nurse is discussing problem-oriented medical
records with a group of newly licensed nurses. Which of the
following information should the nurse include?
A. A problem-oriented medical record is created using the PIE
model for documentation entries.
B. A problem-oriented medical record contains seperate sections
for laboratory and diagnostic information.
C. A problem-oriented medical record promotes information
sharing among members of the interdisciplinary team.
D. A problem-oriented medical record is rarely used in acute care
settings. - answer-C. A problem-oriented medical record promotes
information sharing among members of the interdisciplinary team.
QUESTIONA nurse is discussing the history of electronic health
records (EHRs) during a staff in-service. The nurse should identify
that which fo the following agencies advocated for nationwide use
of EHRs?
A. The Institute of Medicine.
, B. Department of Veteran Affairs.
C. American Hospital Association.
D. The Joint Commission. - answer-A. The Institute of Medicine.
QUESTIONA nurse is preparing to administer morphine 15 mg
PO every 4 hr PRN pain for a client who has a new prescription.
By which of the following routes should the nurse plan to
administer the medication?
A. By mouth
B. Intramuscularly
C. Per rectum
D. Intravenously - answer-A. By mouth
A staff nurse if evaluating a newly licensed nurse's understanding
of telephone prescriptions. Which of the following statements by
the newly licensed nurse indicates an understanding of the
information?
A. "I can take a telephone prescription if a provider is making
routine rounds in another area of the facility."
B. "I can take a telephone prescription if a provider is directing a
code for an unresponsive client."
C. "If a client requires an over-the-counter medicatoin for relief of
nausea, it is okay to accept a telephone prescription."
D. "If a client requires pain control for a terminal condition, it is
okay to accept a telephone prescription." - answer-B. "I can take a
telephone prescription if a provider is directing a code for an
unresponsive client."
QUESTIONA nurse is caring for a client following a stroke. The
nurse should recognize that which of the following individuals is
allowed access to the client's medical record without obtaining
special consent form the client first? (Select all that apply)
A. The admitting provider.
B. The charge nurse of the unit.
C. The client's sibling.
