ATI: Engage Fundamentals RN2.0 –
Documentation Exams.
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. -
CORRECT 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? - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER By mouth
A nurse is preparing an in service about HIPAA. Which of the following information
should the nurse plan to include - CORRECT ANSWER Personnel can be terminated
for breaching a clients confidentialiy
A nurse is discussing computerized provider order entry (CPOE) systems with staff.
Which of the following statements from a staff member indicates an understanding of a
CPOE system? - CORRECT ANSWER CPOE systems can increase the speed of care
delivery
A nurse is discussing problem-oriented medical records with a group of newly licensed
nurses. Which of the following information should the nurse include? - CORRECT
Documentation Exams.
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. -
CORRECT 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? - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER By mouth
A nurse is preparing an in service about HIPAA. Which of the following information
should the nurse plan to include - CORRECT ANSWER Personnel can be terminated
for breaching a clients confidentialiy
A nurse is discussing computerized provider order entry (CPOE) systems with staff.
Which of the following statements from a staff member indicates an understanding of a
CPOE system? - CORRECT ANSWER CPOE systems can increase the speed of care
delivery
A nurse is discussing problem-oriented medical records with a group of newly licensed
nurses. Which of the following information should the nurse include? - CORRECT
