Chapter 5: Documentation - Nurselytic

Questions 9

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ATI LPN TextBook-Based Test Bank

Fundamentals of Nursing Care: Concepts, Connections & Skills

Chapter 5 Questions

Question 1 of 5

Which of the following phrases are written objectively?

Correct Answer: C, E

Rationale: Objective phrases describe observable facts, like ambulation or specific patient statements, without subjective interpretation.

Question 2 of 5

When you use an EHR, you may enter information in which of the following ways?

Correct Answer: A, B, C, D

Rationale: EHRs can be accessed via authorized devices like hand-held computers, hallway stations, nurses' stations, or bedside terminals, but personal laptops are not secure.

Question 3 of 5

Which of the following times during a 7 a.m. to 7 p.m. shift would be appropriate to document on a patient's chart?

Correct Answer: A

Rationale: Documentation should occur as soon as possible after an event to ensure accuracy and timeliness.

Question 4 of 5

Which of the following entries are good examples of succinct charting?

Correct Answer: B, D

Rationale: Succinct charting is specific and concise, like wound measurements or vital signs, avoiding unnecessary detail.

Question 5 of 5

What type of documentation would you, as a nurse, be responsible for performing in the section marked Physician's Orders?

Correct Answer: C, D, E

Rationale: Nurses document transcription details, noting of orders, and verbal orders in the Physician's Orders section.

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