ATI Documentation Assessment
Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
A nurse is documenting a patient's response to pain medication. Which is the best entry?
A. "Client was finally okay."
B. "Client appears comfortable now."
✔✔C. "Client reports pain decreased to 3/10, resting quietly."
D. "Pain medicine worked well."
A nurse makes an error in a written note. What should the nurse do?
✔✔A. Draw a single line through the error, write "error," and initial it.
B. Use correction fluid to cover it.
C. Tear out the page and rewrite it.
D. Scratch it out completely.
Which is a **subjective** documentation entry?
A. "Client's temperature is 101.2°F."
B. "Client has a productive cough."
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,✔✔C. "Client reports feeling nauseated."
D. "Skin warm and dry."
Which documentation is most **objective**?
✔✔A. "Client diaphoretic, respiratory rate 28/min, BP 142/88."
B. "Client anxious and scared."
C. "Client having a bad day."
D. "Client looks terrible."
When documenting a wound assessment, which note is best?
A. "Wound looks better than yesterday."
✔✔B. "Wound measures 2 cm x 3 cm, red edges, moderate serous drainage."
C. "Wound improving."
D. "Seems to be healing."
A nurse receives a verbal order from the provider. What should be documented?
✔✔A. "Verbal order received from Dr. Smith for acetaminophen 650 mg PO every 6 hr PRN
pain. Read back and verified."
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, B. "Doctor said to give Tylenol."
C. "Phone order noted."
D. "Got verbal order."
Which of the following entries follows **best practice** for legal documentation?
A. "Client is acting crazy again."
✔✔B. "Client pacing the room, speaking loudly, refusing care."
C. "Client is being difficult."
D. "Patient annoying today."
Which is the correct way to document a client's refusal of treatment?
✔✔A. "Client refused dressing change, stated, 'I want to wait until my daughter arrives.'"
B. "Client didn’t want it."
C. "Refused, no reason."
D. "Client rude and refused everything."
Which of the following is most appropriate to document in the client record?
A. "I think the client is faking."
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Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
A nurse is documenting a patient's response to pain medication. Which is the best entry?
A. "Client was finally okay."
B. "Client appears comfortable now."
✔✔C. "Client reports pain decreased to 3/10, resting quietly."
D. "Pain medicine worked well."
A nurse makes an error in a written note. What should the nurse do?
✔✔A. Draw a single line through the error, write "error," and initial it.
B. Use correction fluid to cover it.
C. Tear out the page and rewrite it.
D. Scratch it out completely.
Which is a **subjective** documentation entry?
A. "Client's temperature is 101.2°F."
B. "Client has a productive cough."
1
,✔✔C. "Client reports feeling nauseated."
D. "Skin warm and dry."
Which documentation is most **objective**?
✔✔A. "Client diaphoretic, respiratory rate 28/min, BP 142/88."
B. "Client anxious and scared."
C. "Client having a bad day."
D. "Client looks terrible."
When documenting a wound assessment, which note is best?
A. "Wound looks better than yesterday."
✔✔B. "Wound measures 2 cm x 3 cm, red edges, moderate serous drainage."
C. "Wound improving."
D. "Seems to be healing."
A nurse receives a verbal order from the provider. What should be documented?
✔✔A. "Verbal order received from Dr. Smith for acetaminophen 650 mg PO every 6 hr PRN
pain. Read back and verified."
2
, B. "Doctor said to give Tylenol."
C. "Phone order noted."
D. "Got verbal order."
Which of the following entries follows **best practice** for legal documentation?
A. "Client is acting crazy again."
✔✔B. "Client pacing the room, speaking loudly, refusing care."
C. "Client is being difficult."
D. "Patient annoying today."
Which is the correct way to document a client's refusal of treatment?
✔✔A. "Client refused dressing change, stated, 'I want to wait until my daughter arrives.'"
B. "Client didn’t want it."
C. "Refused, no reason."
D. "Client rude and refused everything."
Which of the following is most appropriate to document in the client record?
A. "I think the client is faking."
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