ATI Documentation with Question and answers already solved 2023

ATI Documentation with Question and answers already solved 2023A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following information should the nurse include as a benefit of electronic documentation? The system alerts providers of possible actions that could cause client harm. A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information? "I can take a telephone prescription if a provider is directing a code for an unresponsive client." A nurse in a clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? PRN A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly? Synthroid 100 mg PO every morning ac A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include? A problem-oriented medical record promotes information sharing among members of the interdisciplinary team. A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data? Rebound tenderness noted in RLQ of the abdomen. A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication? By mouth A nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following information should the nurse include? A nurse who delegates a task to an AP will review the charting for that task. A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? Immunization data A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's Do Not Use List? (Select all that apply.) MSO4 IU qhs A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include? (Select all that apply.) Reduces medical errors Makes client medical history more easily available Increases accuracy of coding procedures A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include? Facilities can establish their own rules for documentation methods. A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation? "The client vomited 240 mL of clear emesis but denies pain or nausea." A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods? Charting by exception