ATI LPN
Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 5 : DOCUMENTATION Questions
Question 1 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following rule(s) do(es) not apply to paper documentation?
Correct Answer: D
Rationale: Subjective data documentation is not limited to verbal reports (
D). All other options (A, B, C, E, F, G) are standard paper documentation rules.
Question 2 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Guidelines for paper documentation include which of the following?
Correct Answer: A,D
Rationale: Paper documentation requires signing at shift's end (
A) and including date/time (
D). Cursive is not mandatory (
B), and block charting (
C) is not standard.
Question 3 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. The correct signature for documentation includes which of the following?
Correct Answer: A,E
Rationale: Correct signatures include first and last names (
A) or first initial, last name, and credentials (E). B, C, and D do not meet standard documentation requirements.
Question 4 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Occurrences that should be documented on an incident report form include some of the following. Which ones are included?
Correct Answer: A,B,E,F
Rationale: Incident reports are needed for patient falls (
A), medication errors (
B), staff injuries (E), and unsafe staffing (F). Minor visitor scrapes (
C) and supply issues (
D) are typically not reported.
Question 5 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Some of the following documentation phrases include subjective terminology that needs to be changed to objective terminology. Select the phrases with subjective terms and underline the subjective word(s) that need(s) to be changed to objective.
Correct Answer: C,D,F,G
Rationale: Subjective terms: 'tolerated well' (
C), 'tolerated poorly' (
D), 'got mad' (F), 'bad attitude' (G). These should be replaced with objective descriptions. A, B, and E are objective.