ATI DOCUMENTATION QUESTIONS WITH COMPLETE SOLUTIONS

A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry? The "I" in PIE. The "S" in SOAP. The "R" in DAR. The "E" in PIE. 1 of 20 Term A nurse manager is reviewing the documentation of four newly licensed nurses. Which fo the following medication enteries should the nurse identify as being written correctly? Synthroig 100 mg PO every morning ac Enoxaparin 75 mg SQ bid Digoxin 0.25 mg PO qd Metformin 500.0 mg PO with every meal. 2 of 20 Term A nurse in a clinic is reviewing a client's prescription prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? PRN NPO AC Ad lib 3 of 20 EXAM Term A nurse is talking with a client about their electronic health record (EHR) at the facility. Which fo the following client statements indicates and understanding of EHRs? "I will be able to track my health information." "My personal information will be entered into a national database." "I will have one EHR that will encompass the health care I've received over my lifetime." "The goal of EHR is to improve insurance coding." 4 of 20 Term A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's Do Not Use List? (Select all that apply) A. MSO4 B. IU C. PO D. qhs E. NKA B. The "S" in SOAP. A. The Institute of Medicine. A. By mouth A. MSO4 B. IU D. qhs 5 of 20 EXAM