ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 3 : Documentation Questions
Question 1 of 5
A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patient's initial admission nursing history physical assessment and development of the care plan based on the patient problem identified?
Correct Answer: B
Rationale: The registered nurse (RN) has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified.
Question 2 of 5
Which of the following will the nurse implement when an error is made when documenting in a patient's chart?
Correct Answer: D
Rationale: A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patient's chart. Instead, the nurse should draw a single line through the error, write the word 'error' above it, and sign her name or initials.
Question 3 of 5
What should the nurse be sure to do when documenting in a patient's chart?
Correct Answer: B
Rationale: A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurse's notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line.
Question 4 of 5
A nurse is receiving a telephone order from a health care provider. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the second step of this method?
Correct Answer: B
Rationale: SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation (Kaiser Permanente, 2007). SBAR is considered a safety measure in preventing errors from poor communication during 'hand-off' or 'handover' interactions, the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient. An additional 'R' is added. The additional 'R' (SBARR) represents 'read back' when the nurse reads back the order for clarification.
Question 5 of 5
What are categories of inadequate documentation that may lead to a malpractice claim?
Correct Answer: A,B,C,D
Rationale: Marking out with a single line and initialing is an acceptable method to indicate a charting error.