ATI: RN Documentation Assessment 2.0
revision questions with multiple answers. Be
guided to revise and pass !
A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the
following medication entries should the nurse identify as being written correctly?
- Synthroid 100 mcg PO every morning ac
- Enoxaparin 75 mg SQ bid
- Digoxin 0/25 mg PO qd
- Metformin 500.0 mg PO with evening meal - Correct Answers-Synthroid 100 mcg PO every
morning ac
A nurse is caring for a client following a stroke. The nurse should recognize that which of the
following individuals is allowed to access the client's medical record without obtaining special
consent from the client first? (Select all the apply)
- the admitting provider
- the charge nurse
- the client's sibling
- the client
- the client's spiritual advisor - Correct Answers-- the admitting provider
- the charge nurse
- the client
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 advocate for nationwide EHRs?
- The Institution of Medicine
- Department of Veteran Affairs
- American Hospital Association
- The Joint Commission - Correct Answers-The Institution of Medicine
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following
entries should the nurse identify as meeting the American Nurses Association (ANA) standards
for documentation?
, - "the client is now asleep, and they ate most of their breakfast a few hours ago"
- "the client vomited 240mL of clear emesis but denies pain or nausea"
- "client reports not feeling good, but they look fine"
- "client has 8 to 10 sores on their body" - Correct Answers-"client vomited 240mL of clear
emesis but denies pain or nausea"
A charge nurse is discussing health records with a newly licensed nurse. Which of the following
information should the nurse identify as a component of a health record?
- immunization data
- record of client health care payments
- complete medical information for household members
- facility policies - Correct Answers-immunization data
A nurse is preparing an in-service about HIPPA. Which of the following information should the
nurse plan to include?
- "Accessing the medical record of clients on unit other than where you are assigned is allowed"
- "There are large financial penalties for charting vital signs you obtain for another nurse's
client"
- "Personnel can be terminated for breaching a client's confidentiality":
- "Once you have cared for a client, it is acceptable to look at their medical record on
subsequent health care visits - Correct Answers-"personnel can be terminated for breaching a
client's confidentiality"
A charge nurse is reviewing characteristics of electronic documentation with staff at a providers
office. Which of the following characteristics should the charge nurse plan to include? (Select all
that apply)
- reduces medical errors
- improves listening skills among interdisciplinary team members
- less convenient than paper-based charting
- makes client medical history more easily available
- increases accuracy of coding procedures - Correct Answers-- reduces medical errors
- makes client medical history more easily available
- increases accuracy pf coding procedures
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
revision questions with multiple answers. Be
guided to revise and pass !
A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the
following medication entries should the nurse identify as being written correctly?
- Synthroid 100 mcg PO every morning ac
- Enoxaparin 75 mg SQ bid
- Digoxin 0/25 mg PO qd
- Metformin 500.0 mg PO with evening meal - Correct Answers-Synthroid 100 mcg PO every
morning ac
A nurse is caring for a client following a stroke. The nurse should recognize that which of the
following individuals is allowed to access the client's medical record without obtaining special
consent from the client first? (Select all the apply)
- the admitting provider
- the charge nurse
- the client's sibling
- the client
- the client's spiritual advisor - Correct Answers-- the admitting provider
- the charge nurse
- the client
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 advocate for nationwide EHRs?
- The Institution of Medicine
- Department of Veteran Affairs
- American Hospital Association
- The Joint Commission - Correct Answers-The Institution of Medicine
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following
entries should the nurse identify as meeting the American Nurses Association (ANA) standards
for documentation?
, - "the client is now asleep, and they ate most of their breakfast a few hours ago"
- "the client vomited 240mL of clear emesis but denies pain or nausea"
- "client reports not feeling good, but they look fine"
- "client has 8 to 10 sores on their body" - Correct Answers-"client vomited 240mL of clear
emesis but denies pain or nausea"
A charge nurse is discussing health records with a newly licensed nurse. Which of the following
information should the nurse identify as a component of a health record?
- immunization data
- record of client health care payments
- complete medical information for household members
- facility policies - Correct Answers-immunization data
A nurse is preparing an in-service about HIPPA. Which of the following information should the
nurse plan to include?
- "Accessing the medical record of clients on unit other than where you are assigned is allowed"
- "There are large financial penalties for charting vital signs you obtain for another nurse's
client"
- "Personnel can be terminated for breaching a client's confidentiality":
- "Once you have cared for a client, it is acceptable to look at their medical record on
subsequent health care visits - Correct Answers-"personnel can be terminated for breaching a
client's confidentiality"
A charge nurse is reviewing characteristics of electronic documentation with staff at a providers
office. Which of the following characteristics should the charge nurse plan to include? (Select all
that apply)
- reduces medical errors
- improves listening skills among interdisciplinary team members
- less convenient than paper-based charting
- makes client medical history more easily available
- increases accuracy of coding procedures - Correct Answers-- reduces medical errors
- makes client medical history more easily available
- increases accuracy pf coding procedures
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
