1. A home health nurse is preparing for an initial home visit. Which
information should be included in the patient’s home care medical record?
a. Nursing process form
b. Step-by-step skills manual
c. A list of possible procedures
d. Reports to third-party payers
ANS: D
Information in...
ATI COMMUNITY HEALTH PROCTORED EXAM
1. A home health nurse is preparing for an initial home visit. Which
information should be included in the patient’s home care medical record?
a. Nursing process form
b. Step-by-step skills manual
c. A list of possible procedures
d. Reports to third-party payers
ANS: D
Information in the home care medical record includes patient assessment,
referral and intake forms, interprofessional plan of care, a list of medications,
and reports to third-party payers. An interprofessional plan of care is used
rather than a nursing process form. A step-by-step skills manual and a list of
possible procedures are not included in the record.
2. A nurse in a long-term care setting that is funded by Medicare and
Medicaid is completing standardized protocols for assessment and care
planning for reimbursement. Which task is the nurse completing?
a. A minimum data set
b. An admission assessment and acuity level
c. A focused assessment/specific body system
d. An intake assessment form and auditing phase
ANS: A
The Resident Assessment Instrument (RAI), which includes the Minimum
Data Set (MDS) and the Care Area Assessment (CAA), is the data set that is
federally mandated for use in long-term care facilities by CMS. MDS
assessment forms are completed upon admission, and then periodically, within
specific guidelines and time frames for all residents in certified nursing
homes. The MDS also determines the reimbursement level under the
prospective payment system. A focused assessment is limited to a specific
body system. An admission assessment and acuity level is performed in the
hospital. An intake form is for home health. There is no such thing as an
auditing phase in an assessment intake.
3. A nurse is charting. Which information is critical for the nurse to document? 1
a. The patient had a good day with no complaints.
, ATI COMMUNITY HEALTH PROCTORED EXAM / VERIFIED
b. The family is demanding and argumentative.
c. The patient received a pain medication, Lortab.
d. The family is poor and had to go on welfare.
ANS: C
Nursing interventions and treatments (e.g., medication administration) must
be documented. Avoid using generalized, empty phrases such as “status
unchanged” or “had good day.” Do not document retaliatory or critical
comments about a patient, like demanding and argumentative. Family is poor
is not critical information to chart.
4. A nurse is completing an OASIS data set on a patient. The nurse works in
which area?
a. Home health
b. Intensive care unit
c. Skilled nursing facility
d. Long-term care facility
ANS: A
Nurses use two different data sets to document the clinical assessments and
care provided in the home care setting, the Outcome and Assessment
Information Set (OASIS) and the Omaha System. The intensive care unit does
not use the OASIS data set. The long-term health care setting includes skilled
nursing facilities (SNFs) in which patients receive 24-hour day care.
5. A nurse is preparing to document a patient who has chest pain. Which
information is critical for the nurse to include?
a. The family is a “pain.”
b. Pupils equal and reactive to light
c. Had poor results from the pain medication
d. Sharp pain of 8 on a scale of 1 to 10
ANS: D
You need to ensure the information within a recorded entry or a report is
complete, containing appropriate and essential information (pain of 8).
Document subjective and objective assessment. While pupils equal and
reactive to light is data, it does not relate to the chest pain; this information 2
would be critical for a head injury. Derogatory or inappropriate comments
, ATI COMMUNITY HEALTH PROCTORED EXAM / VERIFIED
about the patient or family (“pain”) is not appropriate. This kind of language
can be used as evidence for nonprofessional behavior or poor quality of care.
Avoid using generalized, empty phrases like “poor results.” Use complete,
concise descriptions.
6. A nurse is providing care to a group of patients. Which situation will
require the nurse to obtain a telephone order?
As the nurse and health care provider leave a patient’s room, the
a. primary care provider gives the nurse an order.
At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and
b. the incision dressing is saturated with blood.
At 0800, the nurse and health care provider make rounds, and the
c. primary care provider tells the nurse a diet order.
A nurse reads an order correctly as written by the health care provider
d. in the patient’s medical record.
ANS: B
Telephone orders and verbal orders (VO) usually occur at night or during
emergencies (blood pressure dropping); they should be used only when
absolutely necessary and not for the sake of convenience. Because the time is
1 AM (0100 military time) and the health care provider is not present, the
nurse will need to call the health care provider for a telephone order. A VO
involves the health care provider giving orders to a nurse while they are
standing in proximity to one another. Just reading an order that is correctly
written in the chart does not require a telephone order.
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