ATI Documentation | All Test In Medicine about Documentation| Health Computing| Questions With Complete Solutions 2023/2024 Guide| Test Bank
ATI Documentation
1
Full Test Bank
ATI Documentation | All Test In Medicine about
Documentation| Health Computing| Questions
With Complete Solutions 2023/2024 Guide
Table of Contents
ATI 7: Documentation……………………………………………………………………………………………..2
ATI Documentation | Multiple Choice …………………………………………………………………….4
ATI Fundamentals Documentation| Multiple Choice …………………………………………… 10
ATI Documentation Assessment| Multiple Choice ………………………………………………. 14
Informatics and Documentation| Multiple Choice……………………………………………….. 20
Documentation of Nursing Care…………………………………………………………………………… 31
ATI: Documentation 2.0| Multiple Choice…………………………………………………………….. 32
ATI Documentation
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ATI 7: Documentation
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?
(Ans: – “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?
(Ans: – 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?
(Ans: – 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?
(Ans: – 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?
(Ans: – 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.
(Ans: – 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?
(Ans: – By mouth
ATI Documentation
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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?
(Ans: – 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?
(Ans: – “The client vomited 240 mL 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?
(Ans: – Immunization data
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?
(Ans: – Facilities can establish their own rules for documentation methods
A nurse is reviewing documentation principals with a group of newly hired assistive
personnel (AP). Which of the following should the nurse include?
(Ans: – A nurse who delegates a task to an AP will review the charting for that task
A nurse in the clinic is reviewing a clients prescriptions prior to discharge. The
nurse should instruct the client that which of the following abbreviations indicates
the medication can be taken as needed?
(Ans: – PRN
A nurse manager is reviewing the documentation of for newly licensed nurses.
Which of the following medication entries should the nurse identify as being
written correctly?
(Ans: – Synthroid 100 mg PO every morning ac
A charge nurse is reviewing soap documentation with a group of newly licensed
nurses. Which of the following chart entries should the nurse include as an example
of objective data?
ATI Documentation
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(Ans: – Rebound tenderness noted in RLQ of the abdomen
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?
(Ans: – Reduces medical errors, makes clients medical history more easily available,
increases accuracy of coding procedures
A nurse is documenting information in a clients chart and makes the entry
quotation mark client reports “abdominal pain on exertion”. Which of the following
documentation format describes this entry?
(Ans: – The S in soap
A nurse is discussing computerized provider order entry systems with staff. Which
of the following statements from a staff member indicates an understanding of a
CPOE system?
(Ans: – CPOE systems can increase the speed of care delivery
A nurse is talking with a client about the electronic health record at the facility.
Which of the following client statements indicates an understanding of EHRs?
(Ans: – I will be able to track my health information
A nurse is preparing an in-service about HIPAA. Which of the following information
should the nurse plan to include?
(Ans: – Personnel can be terminated for breaching a client’s confidentiality
ATI Documentation | Multiple Choice
A staff nurse if 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?
A. “I can take a telephone prescription if a provider is making routine rounds in
another area of the facility.”
B. “I can take a telephone prescription if a provider is directing a code for an
unresponsive client.”
C. “If a client requires an over-the-counter medicatoin for relief of nausea, it is okay
to accept a telephone prescription.”
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