ATI LPN
Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 5 : Documentation Questions
Question 1 of 5
Which document would be found in the Advanced Directive section of a source-oriented medical record?
Correct Answer: B
Rationale: The Advance Directive section contains documents like living wills, which outline patient preferences for care.
Question 2 of 5
Which setting(s) may use Kardexes and paper charts?
Correct Answer: A, B, C, D
Rationale: Kardexes and paper charts may be used in various settings, including hospitals, surgery centers, home health, and long-term care.
Question 3 of 5
When working in long-term care, the nurse is required to document assessment data on a resident how often?
Correct Answer: D
Rationale: In long-term care, resident assessments are typically documented monthly unless otherwise specified.
Question 4 of 5
Which of the following phrases are written objectively?
Correct Answer: C, E
Rationale: Objective phrases describe observable facts, like ambulation or specific patient statements, without subjective interpretation.
Question 5 of 5
When you use an EHR, you may enter information in which of the following ways?
Correct Answer: A, B, C, D
Rationale: EHRs can be accessed via authorized devices like hand-held computers, hallway stations, nurses' stations, or bedside terminals, but personal laptops are not secure.