ATI: Engage Fundamentals RN2.0 –
Documentation Questions and Answers
Rated A+
What information should be included when documenting a patient’s vital signs?
Include the date and time of measurement, the specific vital signs recorded (e.g.,
temperature, pulse, respiration rate, blood pr...
ATI: Engage Fundamentals RN2.0 –
Documentation Questions and Answers
Rated A+
What information should be included when documenting a patient’s vital signs?
✔✔ Include the date and time of measurement, the specific vital signs recorded (e.g.,
temperature, pulse, respiration rate, blood pressure), and any deviations from normal ranges.
How should a nurse document an unexpected change in a patient’s condition?
✔✔ Document the date and time of the change, a detailed description of the condition, any
actions taken, and the patient’s response to those actions.
What is the correct way to document a patient’s allergies?
✔✔ Clearly record the specific allergens, the type of reaction experienced, and any relevant
medical history related to the allergies.
How should a nurse document patient teaching and educational sessions?
✔✔ Note the topics covered, the patient’s understanding and any questions asked, and any
educational materials provided or recommended.
1
, What should be documented if a patient is admitted with a known chronic condition?
✔✔ Document the chronic condition, the current status, any recent changes or complications,
and the patient’s treatment plan or ongoing management.
How does documenting patient consent contribute to nursing practice?
✔✔ Documenting patient consent ensures that the patient is informed about the procedures and
treatments, agrees to them, and provides a legal record of their consent.
What is the importance of documenting patient assessments regularly?
✔✔ Regular documentation of patient assessments helps track changes in the patient’s condition,
ensures timely interventions, and provides a complete record of care over time.
How should a nurse document incidents or errors in patient care?
✔✔ Document the incident or error factually, including what happened, the actions taken to
address it, any patient outcomes, and steps to prevent recurrence.
What should a nurse include when documenting a patient’s response to a new treatment?
✔✔ Document the treatment administered, the patient’s immediate and ongoing response, any
side effects observed, and the effectiveness of the treatment.
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