ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 3 : Documentation Questions
Question 1 of 5
What is the system that classifies patients by age diagnosis and surgical procedure and produces 300 different categories used for predicting the use of hospital resources?
Correct Answer: D
Rationale: Cost reimbursement rates under government plans are based on diagnosis-related groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay.
Question 2 of 5
A nurse is using the data action response education (DARE) system of charting and is completing the data portion. What data are the nurse's focus?
Correct Answer: B
Rationale: DARE is the acronym for four different aspects of charting using the focus format. Data (
D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (
A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E).
Question 3 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 4 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 5 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.