ATI: Engage Fundamentals RN2.0 -
Documentation Complete Mock Exam
[100% Correct] 2024/2025!! NEW
RELEASE!!
What is the primary purpose of documentation in nursing practice?
To provide a permanent legal record of patient care and ensure continuity of care.
Which documentation format allows...
ATI: Engage Fundamentals RN2.0 -
Documentation Complete Mock Exam
[100% Correct] 2024/2025!! NEW
RELEASE!!
What is the primary purpose of documentation in nursing practice?
To provide a permanent legal record of patient care and ensure continuity of care.
Which documentation format allows for a systematic approach to patient assessment and care
planning?
The nursing care plan format.
What does the acronym SOAP stand for in the context of clinical documentation?
Subjective, Objective, Assessment, Plan.
In which section of a patient’s chart would you typically find the nursing diagnosis?
The nursing care plan.
What is the significance of using standardized terminology in nursing documentation?
It enhances communication and reduces misunderstandings among healthcare providers.
Why is it essential to document patient education in the medical record?
To provide evidence of the education provided and the patient's understanding.
1
, How often should vital signs be documented in the patient’s chart?
Every time they are assessed, according to the facility’s protocol.
What is the role of electronic health records (EHR) in nursing documentation?
EHRs facilitate accurate, real-time documentation and improve access to patient information.
Which of the following is considered a breach of confidentiality in documentation?
Sharing a patient’s information with unauthorized individuals.
What is the appropriate action if a nurse makes an error in documentation?
Draw a single line through the error, write the correct information, and initial it.
When documenting patient care, what is the best practice regarding abbreviations?
Use only approved abbreviations to avoid confusion.
What does the acronym DAR stand for in nursing documentation?
Data, Action, Response.
Why is it important to document a patient’s pain level accurately?
To assess the effectiveness of pain management interventions.
2
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