ATI 7: Documentation & Record Keeping
Challenge with Solutions 2023.
A staff nurse is 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? - Correct Answer: "I can take a
telephone prescription if a provider is directing a cide for an unresponsive client."
A nurse is caring for a client after 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 from the client first? - Correct Answer: The
admitting provider, the charge nurse on the unit, the client
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
commissions do not use list? - Correct Answer: MSO4, IU, qhs
A newly licensed nurse is orienting to a facilities documentation process. The
facility requires staff to on,y document variations from an expected set of findings
when performing a physical assessment. The nurse should identify this system as
which of the following documentation methods? - Correct Answer: Charting by
exception
A nurse is discussing problem-oriented medical records with a group of newly
licensed nurses. Which of the following information should the nurse include? -
, ATI 7: Documentation & Record Keeping
Challenge with Solutions 2023.
Correct Answer: A problem-oriented medical record uses progress notes, which
promotes information sharing among members of the interdisciplinary team.
A nurse is discussing the history of electronic health records (EHRs) 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
(IoM)
A 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? - Correct Answer: By mouth
A nurse is taking an admission history from a client who is concerned about the
facility using an electronic documentation system. Which of the following should
the nurse include as a benefit of electronic documentation? - Correct Answer: The
system alerts providers of possible actions that could cause client harm
A nurse is reviewing the documentation of a newly licensed nurse. Which of the
entries should the nurse identify as meeting the American Nurses Association
(ANA) standards of documentation? - Correct Answer: "The client vomited 240 mL
of clear emesis but denies pain or nausea"
Challenge with Solutions 2023.
A staff nurse is 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? - Correct Answer: "I can take a
telephone prescription if a provider is directing a cide for an unresponsive client."
A nurse is caring for a client after 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 from the client first? - Correct Answer: The
admitting provider, the charge nurse on the unit, the client
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
commissions do not use list? - Correct Answer: MSO4, IU, qhs
A newly licensed nurse is orienting to a facilities documentation process. The
facility requires staff to on,y document variations from an expected set of findings
when performing a physical assessment. The nurse should identify this system as
which of the following documentation methods? - Correct Answer: Charting by
exception
A nurse is discussing problem-oriented medical records with a group of newly
licensed nurses. Which of the following information should the nurse include? -
, ATI 7: Documentation & Record Keeping
Challenge with Solutions 2023.
Correct Answer: A problem-oriented medical record uses progress notes, which
promotes information sharing among members of the interdisciplinary team.
A nurse is discussing the history of electronic health records (EHRs) 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
(IoM)
A 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? - Correct Answer: By mouth
A nurse is taking an admission history from a client who is concerned about the
facility using an electronic documentation system. Which of the following should
the nurse include as a benefit of electronic documentation? - Correct Answer: The
system alerts providers of possible actions that could cause client harm
A nurse is reviewing the documentation of a newly licensed nurse. Which of the
entries should the nurse identify as meeting the American Nurses Association
(ANA) standards of documentation? - Correct Answer: "The client vomited 240 mL
of clear emesis but denies pain or nausea"
