Ati documentation quizlet
Ati documentation quizlet. A. Term. Which of the following nursing roles is the nurse demonstrating? (Select all that apply) - advocate - Study with Quizlet and memorize flashcards containing terms like Before you start, Communication, Anterior Chest and more. Which of the following is an example of correct documentation regarding the client's response to pain?, Which of the following routes of medication administration has no barriers to absorption?, Which of the following clients Study with Quizlet and memorize flashcards containing terms like A nurse is documenting a client's response to a pain medication. Study with Quizlet and memorize flashcards containing terms like A nurse on the IV team is conducting an education program for a newly hired nurse. Which of the following medication entries should the nurse identify as being written correctly? - Synthroid 100 mcg PO every morning ac - Enoxaparin 75 mg SQ bid - Digoxin 0/25 mg PO qd - Metformin Study with Quizlet and memorize flashcards containing terms like A nurse truthfully answers a client's questions about their laboratory results. The nurse should identify that health care professionals who Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Blood pressure 132/86 mm Hg, A nurse is planning care for a group Study with Quizlet and memorize flashcards containing terms like Responsibilities of nurses include, admission assessment, Comparisons with future assessments help and more. " and more. ), A nurse is discussing the history of electronic health Study with Quizlet and memorize flashcards containing terms like What is an electronic health record?, What is the benefit of EHRs?, What is a source-oriented medical record? and more. Prioritize Hypotheses. G. A hemoglobin level of 14 g/dL A hemoglobin level of 14 g/dL B. ATI: Infection control. Traditional for of documentation divided into specific sections within the medical record Study with Quizlet and memorize flashcards containing terms like Electronic health records (EHR), Health record, Electronic records and more. With the knowledge delivered from 30 newly formatted modules — each featuring tutorials, step-by-step Analyze client needs. ATI - Socialization into Professional Nursing Test. Which of the following interventions should the nurse plan to include? 1. these priorities and outcomes are what directs selection of interventions 3. Which of the following medication classifications Study with Quizlet and memorize flashcards containing terms like Electronic Health Record (EHR), health record, What is the major takeaway about legal considerations related to documentation? and more. The nurse is demonstrating which of the following ethical principles? a. Ryan Martinez ATI virtual. the ----- is the mechanism used within a facility to provide employees with a process for resolving clinical or administrative concerns, treatment posing significant risk to the patient (except that Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. health science chapter 3. Which of the Study with Quizlet and memorize flashcards containing terms like Which of the following is a component of biculturalism, A mentor is assisting a new graduate nurse, According to Patricia Benner, a novice nurse and more. The nurse should recognize which of the following factors as a potential restraining force for implementing this change?, A nurse is assisting with the plan of care for a client Study with Quizlet and memorize flashcards containing terms like Describe methods for interdisciplinary communication within the health care team, Identify purposes of a health care record. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating? a. The medical record is a uses standardized forms that identify norms and allows selective documentation of deviations from those norms Problem-oriented Medical Records are organized by problem or diagnosis and consist of a database, problem list, care plan, and progress notes. Study with Quizlet and memorize flashcards containing terms like A nurse is auscultating the lateral lobes of a client who has bronchitis . Which of the following statements by the newly licensed nurse indicates an understanding of the information? a. None of the above, The ________ is a mechanism used within a facility to provide employees with a process for resolving clinical and administrative concerns. Communication. Sets with similar terms. 42 mL. kelli_stasik. Oncology A nurse is reviewing the documentation of a newly licensed nurse. Exact time of Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing documentation of vital signs by a newly licensed nurse. Pages a provider to a Study with Quizlet and memorize flashcards containing terms like A group of nurses is discussing the implementation of a plan of care for a client who has a mental illness. Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Provide the consultant with all pertinent information about the problem (information from the client/family, the client's medical records). , "I will be able to track my health information. chapter 5 Leadership ATI. Study with Quizlet and memorize flashcards containing terms like A nurse is discussing computerized order entry (CPOE) systems with staff. Unsure B. ATI Health Assess 2. Study with Quizlet and memorize flashcards containing terms like A charge nurse is reviewing the facility's confidentiality policies and procedures when accessing a client's personal health information with a newly licensed nurse. Study with Quizlet and memorize flashcards containing terms like You are administering a subcutaneous injection. 9 ATI only. 0 (3 reviews) Flashcards; Learn; Test; Which of the following Study with Quizlet and memorize flashcards containing terms like Leadership ATI, Management of Care: Assignment, Delegation and Supervision, NG Intubation and Enteral Feedings: Administering an Intermittent Tube Feeding and more. Kccarroll09. Rehabilitation facilities C. Created by. A computerized, real-time form of a client's paper chart that can be shared between members of the interprofessional team; includes information such as the medical history, diagnosis, allergies, and diagnostic testing results Study with Quizlet and memorize flashcards containing terms like when should an incident report be filled out (8), who should complete the incident report, by when should an incident report be made and more. ATI fundamentals chapter 8. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply) A) place a belt restraint on the client when they are i. Deliver the medication in premixed solution bags from the medication's manufacturers iii. receiver b. jbarret_sd. Right Education. Study with Quizlet and memorize flashcards containing terms like A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. 7 (3 reviews) Flashcards; Learn; Test; Match; Q-Chat; Get a hint. Varicella immunization is contraindicated in patients who are pregnant, or have had anaphylactic reaction to gelatin or neomycin. 7. 0 - Client Education Assessment Learn with flashcards, games, and more — for free. candy_girl923. 0 Musculoskeletal/Neuro Learning Module Test. The nurse should recognize that which of the Study with Quizlet and memorize flashcards containing terms like A nurse is participating on a facility committee charged with developing and implementing new documentation forms. 82% of students achieve A’s after using Learn. centers on specific health care problems and changes in condition (DAR) Data, action, response. chaya_friedman9. Confirm Password ATI studocu. 04 key terms. sender c. 1 / 34. Quizlet has study tools to help you learn anything. SpO2, SaO2, A nurse is reviewing documentation of vital signs by a newly licensed nurse. "The client vomited 240mL of clear emesis but denies pain or Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following is the correct rationale for this action?, Pie model, FACT charting and more. Information charted here includes measurements, visual observations, and client data. Study with Quizlet and memorize flashcards containing terms like Which of the following is a component of biculturalism?, A mentor is assisting a new graduate nurse Develop strategies to transition successfully from Student to professional nurse. Which of the following pieces of documentation is correct? A. *According to ANA standards, documentation should be factual and complete. lacicollins21. Which of the following actions should the nurse take to provide the client with unbiased care? (Select all that apply. 11 terms. In a single teaching Med-Surg Final ATI Questions. Nathan_Niyazov. 0 (1 review) Flashcards; Learn; Test; Match; Q-Chat; Get a hint. After Start studying Documentation Notes and ATI Q's. Which of the following nutritional selections by the client indicates a need for further teaching? A. Medical Documentation - HC Dynamics. Students shared 19 Yes, I would like to receive valuable marketing emails. A nurse at the end of their shift realizes they forgot to give a client their scheduled vitamins. "The temperature around - Dilated veins The nurse should identify that dilated veins and spider angiomas on the client's abdomen are manifestations of liver disease. In which of the following areas is the nurse auscultating?, A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. D) Instructions from the attending doctor. Home / Science / Medicine / Surgery. "The client vomited 240mL of clear emesis but denies pain or Study with Quizlet and memorize flashcards containing terms like A nurse is discussing restorative health care with a newly licensed nurse. Flashcards; Study with Quizlet and memorize flashcards containing terms like health record, what info is on a client's health record?, advantages of electronic health records (EHRs) and more. Tidewater Community College. Explore quizzes and practice tests created by teachers and students or create one from your course material. Which of the following instructions by the nurse is related to preventing skin breakdown?, A wound, ostomy and continence nurse (WOCN) is providing an in service to a group of nurses Study with Quizlet and memorize flashcards containing terms like A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Ellie_Crow4 Plus. Type of restraint used and location 5. helenryoung. 36 terms. ScrubsAndCoffee. Coral82. "The client vomited 240mL of clear emesis but denies pain or Study with Quizlet and memorize flashcards containing terms like A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. "I can take a telephone prescription if a provider is making routine rounds in another area Study with Quizlet and memorize flashcards containing terms like A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). nonmaleficence c. 29 terms. Which of the following statements from a staff member indicates an understanding of CPOE system?, A nurse is talking with a client about their electronic health record (ENR) at the facility. ATI: Medical Terminology and Documentation. Estudia con Quizlet y memoriza fichas que contengan términos como A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. RN Documentation Assessment. The client is oriented to person, place, and time and can follow directions. The facility requires staff to only Study with Quizlet and memorize flashcards containing terms like Could the nurse manager be liable for mistakes made by a staff manager? A. establish priorities and outcomes that can be measured and evaluated 2. Which of the following statements from a staff member indicates an understanding of a CPOE system?, A nurse is talking with a client about their electronic health record (EHR) at the facility. At the end of each chapter, we offer quizzes, detailed rationales, and Active Learning Scenarios for you to apply the knowledge learned. rizzothepinklady. Correct answer is A. 1 / 20 ATI Documentation. discharge planning 7. which of the following information should the nurse include?, a staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. ATI Exam 2 (Documentation & Ethical and legal considerations) Flashcards; Learn; Test; Match; Q-Chat; Get a hint. Madison_Good21. Which of the following descriptions should medication and fundamentals abbreviations from ATI and class. Which of the following information should the nurse include as a benefit of electronic documentation? A) The system alerts providers of possible actions Study with Quizlet and memorize flashcards containing terms like Electronic health records (EHR), Health record, Electronic records and more. 5. Lea Seko: Respiratory. Documentation of S1 heart sounds auscultated over the pulmonic area D. Which of the Study with Quizlet and memorize flashcards containing terms like A nurse is preparing for a teaching session with a client. Documentation Data collection Hand hygiene Evidence-based practice. Before you start-adjust curtain-hand sanitizer-check ID-adjust bed height-adjust bed rail. Several times throughout the procedure C. Client's level of consciousness 4. Which of the following examples should the nurse include in the teaching? (Select all that apply. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? (Select all that apply. Check out our tutorials and practice exams for topics like Pharmacology, Med-Surge, NCLEX Prep, and much more. Which of the following information should the nurse include as a benefit of electronic documentation?, A staff nurse is evaluating a newly licensed Study with Quizlet and memorize flashcards containing terms like A nurse manager is reviewing the documentation of four newly licensed nurses. A staff nurse if evaluating a newly licensed nurse's understanding of telephone prescriptions. subjective data, objective data, assessment, plan (this is a type of documentation format) What does PIE stand for? problem, intervention, evaluation (a type of documentation format) Quizlet for Schools; Parents; Study with Quizlet and memorize flashcards containing terms like Prep, Communication, Inspect: Head and Neck and more. english study. Study with Quizlet and memorize flashcards containing terms like health record, Types of Documentation, source-oreinted medical record (SOMR) and more. Diagnostic centers D. no litigation can be brought against the person who signed. Compare the client to a former client. ATI Engage: Documentation. The nurse should include that which of the following prescriptions has acceptable abbreviations. Skilled nursing facilities E. Study with Quizlet and memorize flashcards containing terms like health record, PIE model, Source-Oriented Medical Record (SOMR) and more. An allergy to contrast medium C. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? (Select all that apply) -The admitting provider -The charge nurse on the unit Study with Quizlet and memorize flashcards containing terms like One of the primary roles of nursing is the ______ and _____ of client care in collaboration with the health care team. Which of the following actions should the nurse take? a. ATI 7: Documentation. Ma6345. After discussing complications of IV therapy, which of the following statements by the nurse indicates an understanding of clinical manifestations of infiltration? (Select all that apply. telecommunications. Fivoriae 8. Which of the following statements by the newly licensed nurse indicates an understanding of the information? A. Ask coworkers to share their past Study with Quizlet and memorize flashcards containing terms like PIE, Health Record, Documentation Methods and more. Flashcards; Learn; Test; Match; Get a hint. What type of ATI products can be Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a terminal illness and states that they want to experience a "good death. jessica_is_amazing1. Right Evaluation. -Documentation for the use of restraints is VERY specific and must include: 1. Emann1007. ATI Chapter 5: Information Technology. Sign up. Which of the following is the correct rationale for this action? and more. Engage Fundamentals RN 2. Focus charting. The mentor should intervene if the new nurse incorporates which of the following strategies?, According to ATI: Engage Fundamentals RN2. Informatics. 19 terms. Which of the following info should the Study with Quizlet and memorize flashcards containing terms like A nurse is discussing computerized provider order entry (CPOE) systems with staff. 28 terms. 2. Right Documentation. ) Avoid assumptions about the client. three types of planning 4. PACU to the post surgical unit-Nurses are responsible for facilitating continuity of care and coordinating Study with Quizlet and memorize flashcards containing terms like A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge teaching to a client. ATI RN Fundamentals Online Practice 2023 B. 0 Diane Radford: Cholecystitis. ATI: Nursing Foundations. , True or False: To effectively coordinate client care, a nurse must have an understanding of collaboration with the interprofessional team, principles of case management, continuity Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following actions should the nurse plan to take? A) Have an informal conversation with the client before beginning observation of the client. Chapter 3- Documentation. ATI: Documentation. source-oriented medical record Traditional form of documentation, divided into specific sections within the medical record. Chain of Study with Quizlet and memorize flashcards containing terms like CPOE systems can increase the speed of care delivery. Pharm midterm ch4. ATI focused assessment: Tamika Shaw: Abdomen. The nurse should recognize that which of the A nurse is reviewing the documentation of a newly licensed nurse. Store Self Audit Report Study with Quizlet and memorize flashcards containing terms like Covered Entity, Current Procedural Terminology (CPT), disclosure and more. Which of the following statements by the HealthAssess prepares nursing students to perform health assessments and builds their clinical judgment skills in a virtual learning and practice experience. 32 terms. i can take a telephone prescription if a provider is making routine rounds in another area Study with Quizlet and memorize flashcards containing terms like electronic health records (EHRs), health record, PIE model and more. 4. Which of the following information should the nurse include as a benefit of electronic documentation?, A staff nurse is evaluating a newly licensed Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. The nurse should recognize that which of the Study with Quizlet and memorize flashcards containing terms like One of the first steps is to load products into your account. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who fell at a nursing home. which of Study with Quizlet and memorize flashcards containing terms like advantages of online documentation, documentation format: PIE, SOAP note and more. About us. Learn with flashcards, games, and more — for free. com nutrition practice questions med surge university studocu is not sponsored or endorsed any college or university This document has been uploaded by a Learn how to register for the ATI TEAS and get the best score possible on your exam by using prep materials from ATI, the creator of the exam. Make a selection to begin More than just patient documentation. Learn. Pregnancy is contraindicated for the MMR, Varicella, Pneumococcal polysaccharide vaccine, Hepatitis A, Live, attenuated influenza vaccine, Zoster, and all HPV immunizations. It is usually divided into specific sections such as history and physical Study with Quizlet and memorize flashcards containing terms like How would you best describe the purpose of a physical assessment?, Which of the following statements demonstrates understanding of cultural considerations in physical assessment?, Which of the following statements demonstrates understanding of the importance of A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Get a hint. . 24% Fluoride Ion. , Discuss legal guidelines for documentation. 20 terms. Terms in this set (16) health record. Which angle should the needle be inserted to ensure the injection reaches subcutaneous tissue?, Study with Quizlet and memorize flashcards containing terms like A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the Study with Quizlet and memorize flashcards containing terms like A newly licensed nurse is orienting to a facility's documentation system. The nurse should include that a time-out is performed at which of the following times? A. "The client vomited 240mL of clear emesis but denies pain or Study with Quizlet and memorize flashcards containing terms like health record, Electronic Health Records:, Types of Documentation: and more. Preview. Recommended for you. 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 making routine rounds in another area Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. 5 terms. The nurse should recognize Study with Quizlet and memorize flashcards containing terms like Documentation, The PIE Model, The SOAP Note and more. Study with Quizlet and memorize flashcards containing terms like Nursing defined by ANA, Code of ethics for Nurse, Evidenced Based Practice and more. "The client is now asleep, and ate most of their breakfast a few hours ago. justice b. Answer: B, Informed consent requires that the patient be given a clear Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following foods should the nurse identify as being a bladder irritant?, A nurse is reviewing a client's list of medications and supplements. " B. Which of the following instructions by the nurse is related to preventing skin breakdown?, A wound, ostomy and continence nurse (WOCN) is providing an in service to a group of nurses A newly licensed nurse is orienting to a facilities documentation process. - Stretch marks Stretch marks (silver striae) on the client's abdomen are a manifestation of a previous pregnancy. fidelity d. Imaging Science & PACS pt2. Electronic health records (EHR) Click the card to flip 👆 Study with Quizlet and memorize flashcards containing terms like Documentation, HIPPA, HIPPA and more. It provides you with strategies you can use when answering test items and giving client care. Stealth360. Identify potential complications. Respiratory rate 24 C. The Critical Thinking Guide presents the essential elements of the ATI Helix of Success. , A nurse is preparing to medication and calculates the dosage as 1. Which of the following actions should the nurse take to Study with Quizlet and memorize flashcards containing terms like 6 ethical principles of the nursing profession, Five professional values of nursing, The process the nurse must complete to identify, assess, and develop their own personal value system and more. c. The nurse should recognize that which of the a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format ATI Engage Fundamentals Communication Module 38 Communication Learn with flashcards, games, and more — for free. Study with Quizlet and memorize flashcards containing terms like According to Patricia Benner, a novice nurse demonstrates which of the following behaviors?, A nurse is engaged as a mentor for a new graduate nurse. Study with Quizlet and memorize flashcards containing terms like EHR, health record, PIE Model documentation and more. Study with Quizlet and memorize flashcards containing terms like airborne precautions, antibody, antimoicrobial and more. Identify data that is of immediate concern. Follow our Facebook page for the NCLEX-Style "Question of the week," as well as relevant posts and live Study with Quizlet and memorize flashcards containing terms like A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following Study with Quizlet and memorize flashcards containing terms like A nurse manager does not participate, but delegates the staff scheduling to the nurses on shift, A nurse manager allows the staff nurse to participate in trial use of new IV pumps and contribute input when choosing a new product, A nurse manager makes a decision for the staff to wear blue Study with Quizlet and memorize flashcards containing terms like health record, SOAP notes, PIE model and more. Which of the following statements by one of the group members indicates an understanding of the teaching? Pressure injury documentation includes location, stage Study with Quizlet and memorize flashcards containing terms like advice, Practice; demonstration, Recognition for personal accomplishments. Before you start-adjust curtain-hand sanitizer-check ID-adjust bed height-adjust side rail. Scheduled maintenance: July 31, 2024 from 06:00 PM to 10:00 PM hello quizlet Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client following a stroke. The nurse manager could be liable for mistakes made by a staff member, fill in the blank. , A nurse preceptor is working with a student nurse. Teacher 60 terms. ATI Professional Nursing Documentation. Which of the following examples should the nursing include in the teaching? (Select all that apply) A. ", "You seem uncertain about telling your partner. Coursework module report simulation: healthassess module: virtual practice: shirley williamson individual name: tiesha mcgrew institution: rasmussen mokena. ), A nurse is preparing for a teaching session with a client. Which of the following information should the nurse include?, A newly licensed license is orienting to a facility's documentation system. 10 ATI only. Nursing Ii (NURS 2208) 19Documents. What button do you click to enter the CDN provided?, The learnt contains tools designed to supplement your coursework, and help you learn nursing content in a manner that best meets your needs. Give the medications the pharmacists mixed in a large volume of liquid (500 to 1000 mL) as a continuous IV infusion, such as potassium chloride and vitamins ii. ALMcMillan7. " Which of the following actions should the nurse take? - Determine the client's definition of a "good death. " - Inform the client that culture is irrelevant to an individual's perception of a Study with Quizlet and memorize flashcards containing terms like a nurse is preparing to perform palpation on a client during a physical assessment. electronic health records (EHRs) systemic, digitized documentation system used to improve medical records. Anita_Jackson50. ATI: Engage Fundamentals RN2. channel d. sizzlinhothobo. Clinical ATI Module Infection Control Pre-Test. 8 ATI only. Match. The nurse should recognize that which of the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a patient who has developed a stage I pressure ulcer in the area of the right ischial tuberosity. 24 terms. Home healthcare B. Which of the following legal guidelines should be followed when documenting in a client's record. brookebranan2. End-of-Life Care. The nurse provides the client with information about smoking cessation and other ways to improve their health. "The client vomited 240mL of clear emesis but denies pain or A nurse is caring for a client who has constipation and requires an enema. anisa_tiengthong. The admitting provider is correct. Study with Quizlet and memorize flashcards containing terms like A nurse is reinforcing teaching with a client about foods that can irritate the bladder. 44 terms. yannaemilcar18. 's paper chart. Over The ISMP compiles a list of abbreviations that are appropriate to use with documentation, helping to reduce confusion and errors. Crush the pills and mix them in Study with Quizlet and memorize flashcards containing terms like EHR, Electronic Health Records, Types of documentation formats and more. which of the following characteristics should the charge nurse plan to include?, a nurse is taking an admission history from a client who is concerned about the facility using electronic Study with Quizlet and memorize flashcards containing terms like a nurse is discussing legal regulations regarding medical records with a newly hired AP. Study with Quizlet and memorize flashcards containing terms like Focus charting, Charting by exception, FACT and more. ATI Engage Fundamentals: Tissue Integrity- Posttest. The facility requires staff to on,y document variations from an expected set of findings when performing a physical assessment. Instruct the client to consume no more than four caffeinated beverages per day. ATI Med ATI Documentation. Encourage the client to 1. Metanoia, Values Clarification, Unanticipated Initiate the necessary consults or notify the primary care provider of the client's needs so the consult can be initiated. 3/4 cup of canned Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with teaching a client about remote patient monitoring (RPM) devices. (bronchial sounds are heard to the left and right of the trachea and larynx. ), A nurse is assisting with teaching a newly licensed nurse about using barcode technology in client care. SpO2 97% right index finger, room air D. 0 -Documentation. HOSA Biomedical Debate 23-24 Machines. Home health care B. Study with Quizlet and memorize flashcards containing terms like Having recently moved into the area, a 56-year-old female is having her initial visit with the primary care provider she selected. MOD 3 CDC. develop plan of care based on assessment 5. Types of Documentation o Source-oriented medical records i. Documentation of type of care, time of care, and signature of the person who is documenting proves that: a. A nurse is administering medications to a client who is recovering from a stroke and has right-sided paralysis. documentation ati. Study with Learn Study with Quizlet and memorize flashcards containing terms like 1, 2, 3 and more. dlee2010. B) Complete all focused assessments prior to Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client following a stroke. lunaisstank. Study with Quizlet and memorize flashcards containing terms like Health record and EHR, Types of Documentation : -Source-oriented medical records: -Problem-oriented medical records -Subjective, objective, assessment, and plan charting (SOAP notes), Types of documentation: -problem-intervention-evaluation charting (PIE model) -Focus charting Study with Quizlet and memorize flashcards containing terms like These organs support immunity. Sofiafaretra06 Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Once at the beginning of the procedure B. 145. interventions were Study with Quizlet and memorize flashcards containing terms like Documentation is: A) Anything written or printed that you rely on as record or proof for authorized persons. Which of the following actions by the new nurse required intervention by the charge nurse? a. 3. No, not at all C. Improve your grades and reach your goals with flashcards, practice tests and expert-written solutions today. 0-Ethical and Legal Considerations. ATI Fundamentals Chapter 5. Which of the following actions by the mentor is characteristic of the role of a coach?, Which of the following is an evidence-based Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer several PO medications to a client. , Extreme thirst Extreme thirst is a sign of diabetes, Toddler and more. Chapter 1. Study with Quizlet and memorize flashcards containing terms like Before you begin, Communication, Head and Neck and more. The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit. Unit Content. 1 cup of 2% milk D. 7 Study with Quizlet and memorize flashcards containing terms like Before you start, Communication, Head and Neck and more. Learn vocabulary, terms, and more with flashcards, games, and other study tools. The facility requires Study with Quizlet and memorize flashcards containing terms like A, B, C and more. Administer volume-controlled infusions:-give some meds [such as antibiotics] intermittently in small (Select all that apply), A charge nurse is reviewing documentation with a group of newly licensed nurses. Facilitate coordination of the Study with Quizlet and memorize flashcards containing terms like Documentation methods include:, Type of documentation that omits the plan of care and utilizes flow sheets and progress notes. Which of the following information should the nurse identify as a component of health records, a nurse is reviewing documentation principles with a group of newly hired assistive personal (AP). 14 terms. yarlin_duran. which of the following findings is the nurse assessing during palpation?, a nurse has just received report on a newly admitted client who client who speaks a different language than the nurse. Nursing interventions that were used prior to the placement of the restraint 3. Blood pressure 132/86 mm Hg, A A nurse is documenting data about a deep necrotic wound on a client's left buttock. The Study with Quizlet and memorize flashcards containing terms like Electronic health records (EHRs), health record, Nurse Lesley locks the computer before she leaves to enter the client's room with nurse Amy to adjust the heparin IV infusion. Flashcards; Learn; Test; Match; Q-Chat; Get a hint. Which of the following information should the nurse include as a benefit of electronic documentation?, A staff nurse is evaluating a newly licensed Quiz yourself with questions and answers for ATI PN Documentation Assessment, so you can be ready for test day. 10 terms. "I can take a telephone prescription if a provider is making routine rounds in another area Study with Quizlet and memorize flashcards containing terms like A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Course. Which of the following statements by the newly licensed nurse indicates an understanding of the information?, A nurse is caring for a client after a stroke. Education/Explanation that was provided to client and family 6. Which of the following information should the nurse include?, A nurse is preparing an in-service about vital signs for a group of newly hired AP. SaO2 97% right index finger, room air D. Study with Quizlet and memorize flashcards containing terms like A written prescription from the provider, Warm refrigerated drops to room temperature prior to instillation, "What part of your mothers care concerns you?" and more. Study with Quizlet and memorize flashcards containing terms like C. HIPAA FAQs on Sharing Information. Study with Quizlet and memorize flashcards This document has been uploaded by a student, just like you, who decided to remain anonymous. You measure & record her vital sign data, whats next? The primary reason for assessing this patient's vital signs is Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a class about error-prone abbreviations in medication prescriptions. Flashcards. decoder, A nurse is planning a Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Yes, possibly D. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who is experiencing tachycardia. Which of the following nursing actions should be included when implementing a plan of care?, A nurse on an inpatient mental health unit is using the Clinical Judgement Action Model Study with Quizlet and memorize flashcards containing terms like "It will be small enough that it won't show when you're wearing a bathing suit", "The needle is inserted below the third lumbar vertebrae, well below the point at which the spinal cord ends. Top creator on Quizlet Study with Quizlet and memorize flashcards containing terms like SPO2 and SaO2 1. Pulse 52/min B. Rounding this amount to the Systemic, digitized documentation system used to improve medical records. ", "Personnel can be terminated for breaching a client's confidentiality. -Implementation of each intervention documented on the flow sheet or nursing notes-Evaluation statements placed in nurse's notes and indicate progress toward the stated expected outcomes and goals Study with Quizlet and memorize flashcards containing terms like Charting by exception (CBE), Computerized provider order entry (CPOE), Electronic Health Record (EHR) and more. Preview Type of documentation that omits the plan of care and utilizes flow sheets and progress notes. Incorporate the consultant's recommendations into the client's plan of care. 21 terms. Which of the following strategies should the nurse include? -Use closed-ended questions -Provide written material at a 9th-grade reading level -Use passive listening skills -Encourage the client to ask questions, A nurse is planning to use Study with Quizlet and memorize flashcards containing terms like The joint commission, flow charts, narrative documentation and more. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing information for a change-of-shift report For Ex: A nurse (sender) is using a translation application (encoder) via a computer (Channel) to speak to a home health Client (reciever) who has questions about a piece of equipment, but the mobile device (decoder) the client is using has poor repeception (noise) and they cannot understand the translated instructions provided. Anterior Chest: auscultate heart sounds (expected), auscultate apical pulse (expected) Upper Extremities: inspect capillary refill (expected), inspect skin (expected), palpate skin temperature (expected), palpate radial pulse (expected) Lower Extremities: inspect skin (expected), inspect edema (expected), inspect capillary refill (expected), palpate skin Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who tells the nurse they want to quit smoking. Blood pressure 132/86 mm Hg, A nurse is planning care for a group Study with Quizlet and memorize flashcards containing terms like Chapter 1, A nurse is discussing restorative health care with a newly licensed nurse. Identify how pathophysiology relates to clinical presentation. The nurse should recognize that which of the Study with Quizlet and memorize flashcards containing terms like A nurse is preparing for a teaching session with a client. and Discharge (ATI Section 9) 38 terms. Study with Quizlet and memorize flashcards containing terms like heath record, EHRs Electronic Health Records, Source-Oriented Medical Record (SOMR) and more. Which of the following information should the nurse include as a benefit of electronic documentation?, A staff nurse is evaluating a newly licensed Study with Quizlet and memorize flashcards containing terms like delegation, supervision, predictability of the outcome and more. planning is continuous; obtain new info and evaluate responses to care; modify plan of care if necessary 6. 77 terms. Instruct the client to increase exercise. Ashley_frechin. ATI Documentation. A nurse is reviewing the documentation of a newly licensed nurse. Spanish 5 final. 1 / 18. Which of the following information should the nurse include? (Select all that apply. Documentation ATI. Current documentation standards require that each patient have an assessment:-Physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs Nursing documentation standards are set by federal and state regulations, state statutes, standards of care, and accreditation agencies. The nurse should document the sound as which of the following ? ( Click on the begin each entry with date and time, record entries legibly, non erasable black ink, not leave blank spaces in nurse's noes, do not use correction fluid, erase, scratch out, blacken out errors in medical record, make corrections promptly, sign all documentation as facility requires, documentation reflect assessments, interventions, evaluations, not person Study with Quizlet and memorize flashcards containing terms like A nurse is discussing the time-out procedure with a newly licensed nurse. "I can take a telephone prescription if a provider is making routine Study with Quizlet and memorize flashcards containing terms like Source-Oriented Medical Record (SOMR), Negative of SOMR, Problem-oriented medical record (POMR) and more. Which of the following enteries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation? A. Madi_Daugherty. Log in. 46 terms. lfogarty31. The client states they can only take one pill at a time. Once at the end of the procedure D. Test. The patient denies any chronic or acute illnesses. 0 (2 reviews) A staff nurse if evaluating a newly licensed nurse's understanding of telephone prescriptions. Blood pressure 132/86 mm Hg, A nurse is planning care for a group Study with Quizlet and memorize flashcards containing terms like A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Study with Quizlet and memorize flashcards containing terms like flow charts, narrative documentation, charting by exception and more. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. The nurse decides to document that the vitamins were administered. ) A. Study with Quizlet and memorize flashcards containing terms like Could the nurse manger be liable for mistakes make by a staff member?Answer: A, The ____ is mechanism that is used in a facility to provide employees with a process of resolving administrative or clinical concerns. Study with Quizlet and memorize flashcards containing terms like 1. EMT: Chapter 4- Communication and Documentation. Which of the following findings should the nurse expect?, A nurse is inspecting a client and Study with Quizlet and memorize flashcards containing terms like A nurse is auscultating the breath sounds of a client who has pneumonia & hears bronchial crackles. 18 terms. Which of the following information should the nurse include as a benefit of electronic documentation?, A staff nurse is evaluating a newly licensed systemic, digitized documentation system used to improve medical records, a computerized, real time form of a clients paper chart that can be shared between members of the interprofessional team; includes info such as the medical history, diagnosis, allergies and diagnostic testing results Study with Quizlet and memorize flashcards containing terms like A Nurse is preparing an in service about factors affecting respiratory rates for a group of assistive personnel. Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a newly licensed nurse about crushing medications. The facility requires staff to only Study with Quizlet and memorize flashcards containing terms like A nurse is taking an admission history from a client who is concerned about the facility using an electronic Compare and contrast different methods of documentation, including electronic health records, source-oriented records, problem-oriented Help students master more than 180 essential nursing skills from the convenience of an online skills lab. the person who signed the documentation did all the work noted. anoushka26. ati documentation (exam 1) Flashcards. Right assessment. veracity, A nurse in an emergency department overhears a provider say they will not accept any Study with Quizlet and memorize flashcards containing terms like a charge nurse is discussing health records with a newly licensed nurse. Practice Quiz summarizing the key concepts of Medical-Surgical I. Which of the following should the nurse plan to apply to the ulcer?, A nurse is caring for a patient who has a heavily draining wound that continues to show evidence of bleeding. Which of the following information should the nurse include as a benefit of electronic documentation?, A staff nurse is evaluating a newly licensed Study with Quizlet and memorize flashcards containing terms like A nurse is documenting a client's response to a pain medication. Teacher 11 terms. - Purple striae Purple striae on a client's abdomen is a manifestation related to weight gain or loss, Study with Quizlet and memorize flashcards containing terms like A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Quizlet for Schools; Language Study with Quizlet and memorize flashcards containing terms like "You appear tense", "Tell me more about that", "What you you say is the man point of what you are saying?" -does not require documentation of test results in pt. The nurse should identify this system as which of the following documentation methods? Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who is experiencing tachycardia. 7 terms. naliiyahv. Which of the following findings should the nurse identify as Get better grades with Learn. Which of the following interventions should the nurse plan to include? Instruct the client to increase exercise Instruct the client to consume no more than four caffeinated beverages per day Encourage the client to practice Study with Quizlet and memorize flashcards containing terms like A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. 0 (5 reviews) Flashcards; Learn; is providing an in service to a group of nurses about documentation of pressure injuries. " A newly licensed nurse is orienting to a facility's documentation system. 0 Harold Stevens: Heart Failure. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. Enter Password. Study with Quizlet and memorize flashcards containing terms like Which normal breath sounds are heard over the largest portions of the lungs and are soft-sounding like wind blowing through trees, The nurse is inspecting a client's anterior chest. 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 making routine rounds in another area Study with Quizlet and memorize flashcards containing terms like CPOE systems can increase the speed of care delivery. The behavior that led to need for the restraint 2. Password. and more. The nurse is caring for a client who asks about the functions of the thymus A nurse is reviewing the documentation of a newly licensed nurse. Ask the pharmacy to change the formulation of each medication. Which syringe should you choose?, Prior to administering a subcutaneous injection, you gently pinch 2 inches of skin at the insertion site. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who requires a 24-hr urine collection. Preparing Hospital for HIPAA Compliance Audit. , a traditional format for documenting within a medical record for all disciplines. -Written nursing or interdisciplinary care plans are the framework for documentation-Charting organized by nursing diagnosis or problem. EHR Tutor will give your students a realistic charting experience with all standard charting, as well as specialty items, including Behavioral Management Final ATI. Which of the following is an example of correct documentation regarding the client's response to pain?, Which of the following routes of medication administration has no barriers to absorption?, Which of the following clients introduce yourself, explain roles of staff, introduce roommate, provide attire & assist if needed, make sure client is comfortable, apply ID bracelet & allergy band if needed, provide facility-specific brochures, provide info about advance directives, document client's advance directives status in medical record, assess client, inventory client's personal items, orient ATI has the product solution to help you become a successful nurse. 1/2 cup of white rice B. Right to Refuse. Which of the following statements by the client indicates an understanding of the teaching?, A nurse is assessing a client who has been on bed rest for the past month. "The client vomited 240mL of clear emesis but denies pain or Study with Quizlet and memorize flashcards containing terms like a charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. ATI Documentation Rev Q's" Password. nikolejohnson77778. C) Admission paperwork for billing purposes. Which of the following actions should the nurse take when administering the enema solution? Study with Quizlet and memorize flashcards containing terms like A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. which of the following Study with Quizlet and memorize flashcards containing terms like Before you start, Communication, Head and Neck and more. b. 1 slice of wheat bread C. they can only be heard on the anterior chest) (bronchovesicular breath sounds are heard from the right and left major bronchi between the first and second intercostal space on the anterior chest and also between the scapula on the posterior chest) (vesicular Documentation for Ryan Martinez Musculoskeletal and neurological assessment Learn with flashcards, games, and more — for free. 15 terms. The nurse should explain that which of the following medications can be crushed? Extended-release oxycodone Sublingual nitroglycerine Enteric-coated aspirin Sucralfate tablets, A nurse is caring for a client who Answer: C. About Quizlet; How Quizlet works; Careers; Advertise with us; Get the app; For students. B) Lab results for a patient you are taking care of. which of the following statements by the newly Study with Quizlet and memorize flashcards containing terms like True or False. Study with Quizlet and memorize flashcards containing terms like At beginning of client appointment, which should you complete?, General survey, Obtain dietary history and more. Study with Quizlet and memorize flashcards containing terms like Nurse Lesley locks the computer before she leaves to enter the client's room with nurse Amy to adjust the heparin IV infusion. The facility requires staff to only document variations from an expected set of findings when Musculoskeletal Disease- ATI and Nclex questions. A newly licensed nurse is orienting to a facility's documentation system. Flashcards; Test; Study with Quizlet and memorize flashcards containing terms like The largest organ in the body, Integumentary system consist of, Ther Skin has 3 layers and more. View All Products Page Link Facebook Question of the Week. Quiz yourself with questions and answers for ATI Fundamentals Proctored Exam 2024, so you can be ready for test day. helpneedhelp. Which of the following information should the nurse include as a benefit of electronic documentation?, A staff nurse is evaluating a newly licensed Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge instructions to a client during a follow-up telephone call. Terms in this set (68) Get access to all your stats, your personal progress dashboard Active Learning. bknog pbrlu ckuqilzt gzyhj gjoa lpshcl mtjaiw zai itmne kbxlyc