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 these following are sections of a source-oriented chart?
Correct Answer: A,B,C,D,E,F
Rationale: Source-oriented charts include database (
A), graphic sheet (
B), laboratory (
C), medication administration record (
D), nurse's notes (E), and physician's notes (F), as they are standard sections for organizing patient data.
Question 2 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of these following types of data should be included in weekly summaries in a long-term care facility?
Correct Answer: A,B,D,E,F,G
Rationale: Weekly summaries should include prosthesis use (
A), activity level (
B), continence (
D), speech ability (E), visitors (F), social activities (G), self-care ability (I), and diet (J). Length of stay (
C), staff conflicts (H), and payment status (K) are not typically included.
Question 3 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following charting 'omissions' (meaning they were not charted) would carry potential legal risks just by the nature of the omission?
Correct Answer: B,C,D,F
Rationale: Omitting a rash/swelling (
B), hemophilia history (
C), medication order (
D), or NPO order (F) poses legal risks due to potential harm. Meal time (
A) and oral intake instruction (E) are less critical.
Question 4 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. You can safely delegate documentation of certain data to an unlicensed staff member. Which of the following data cannot be delegated?
Correct Answer: A
Rationale: Medication administration documentation (
A) cannot be delegated, as it requires a licensed professional. Vital signs (
B) and flow sheet items (C,
D) can typically be delegated to unlicensed staff.
Question 5 of 5
Indicate whether the following statements are True (T) or False (F). Statistics such as rates of hospital-acquired infections, mortality rates, success rates of specific procedures, and number of incidents and accidents serve as factors of a medical facility's reputation.
Correct Answer: A
Rationale: True (T): These statistics are key indicators of a facility's performance and influence its reputation.