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. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
Correct Answer: B
Rationale: Logging off (
B) prevents unauthorized access and alterations. Charting in code (
A) is not standard, privacy (
C) is important but not preventive, and passwords (
D) are for access, not alteration prevention.
Question 2 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which are accurate statements about EHR?
Correct Answer: B,D
Rationale: EHR is a lifetime health record (
B) and nurses should only access assigned patients' records (
D). A is false as it includes specialists, C is false as precautions are needed, and E is false as EHR is not limited to hand-held devices.
Question 3 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. In which facilities might EHR be used?
Correct Answer: A,B,C,D,E
Rationale: EHR is used in hospitals (
A), clinics (
B), labs (
C), pharmacies (
D), and home health (E) for comprehensive health data management.
Question 4 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 5 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.