PN Fundamentals ATI Proctored | Readiness Benchmark
Q&A: Expert-Reviewed Knowledge Test for 2025/2026
Flow charts are used to record and show trends in: - correct answer vital signs, blood
glucose levels, pain level, and other frequently performed assessments
Narrative documentation records information as - correct answer sequence of events
Charting by exception - correct answer shorthand method for documenting patient data
that is based on well-defined standards of practice; only exceptions to these standards
are documented in narrative notes
problem-oriented medical record (POMR) - correct answer documentation system
organized according to the person's specific health problems; includes database,
problem list, plan of care, and progress notes
Electronic Health Record (EHR) - correct answer An electronic record of health-related
information on an individual that conforms to nationally recognized interoperability
standards and that can be created, managed, and consulted by authorized clinicians
and staff across more than one healthcare organization
Change of shift report - correct answer -given at the conclusion of each shift by the
nurse leaving to the nurse assuming responsibility for the client
-can be given face-to-face, audiotaped, or presented during rounds
-should include significant objective info, given in logical order, free of gossip and
personal opinions, and relate recent changes in meds, treatments/procedures, or
discharge plan
Telephone reports - correct answer To document a phone call, the nurse includes
when the call was made, who made it (if other than the writer of the information), who
was called, to whom information was given, what information was given, and what
information was received.
, telephone or verbal prescriptions - correct answer best to avoid these, but they are
sometimes necessary during emergencies and at unusual times. have a second nurse
listen to a telephone prescription, repeat it back, making sure to include the medication's
name (spell if necessary), dosage, time, and route. question any prescription that may
seem inappropriate for the client. make sure the provider signs the prescription in
person within the time frame the facility specifies typically 24 hrs.
Incident reports (unusual occurrences) - correct answer -important part of a facility's
quality improvement plan
-examples of incidence include med errors, falls, and needle sticks
-facts documented without judgment or opinion
-should not be referred to in client's medical record
SOAP - correct answer subjective, objective, assessment, plan
PIE - correct answer problem, intervention, evaluation
DAR - correct answer (focus charting) Data, Action, Response
Privacy rule of HIPAA - correct answer -protects all individually identifiable health
information held or transmitted by a hospital (or other covered entity/business
associate) in any form of media.
-privacy rule call this information protected health information (PHI)
Hand Hygiene (Hand Washing) - correct answer -Lather all surfaces (wrists, hands, &
fingers), creating friction, for at least 20 seconds.
-Keep hands lower than elbows & fingertips down
-Rinse all surfaces (wrists, hands, & fingers), keeping hands lower than elbows &
fingertips down
two minute hand wash - correct answer must be done when hands are visibly soiled.
Q&A: Expert-Reviewed Knowledge Test for 2025/2026
Flow charts are used to record and show trends in: - correct answer vital signs, blood
glucose levels, pain level, and other frequently performed assessments
Narrative documentation records information as - correct answer sequence of events
Charting by exception - correct answer shorthand method for documenting patient data
that is based on well-defined standards of practice; only exceptions to these standards
are documented in narrative notes
problem-oriented medical record (POMR) - correct answer documentation system
organized according to the person's specific health problems; includes database,
problem list, plan of care, and progress notes
Electronic Health Record (EHR) - correct answer An electronic record of health-related
information on an individual that conforms to nationally recognized interoperability
standards and that can be created, managed, and consulted by authorized clinicians
and staff across more than one healthcare organization
Change of shift report - correct answer -given at the conclusion of each shift by the
nurse leaving to the nurse assuming responsibility for the client
-can be given face-to-face, audiotaped, or presented during rounds
-should include significant objective info, given in logical order, free of gossip and
personal opinions, and relate recent changes in meds, treatments/procedures, or
discharge plan
Telephone reports - correct answer To document a phone call, the nurse includes
when the call was made, who made it (if other than the writer of the information), who
was called, to whom information was given, what information was given, and what
information was received.
, telephone or verbal prescriptions - correct answer best to avoid these, but they are
sometimes necessary during emergencies and at unusual times. have a second nurse
listen to a telephone prescription, repeat it back, making sure to include the medication's
name (spell if necessary), dosage, time, and route. question any prescription that may
seem inappropriate for the client. make sure the provider signs the prescription in
person within the time frame the facility specifies typically 24 hrs.
Incident reports (unusual occurrences) - correct answer -important part of a facility's
quality improvement plan
-examples of incidence include med errors, falls, and needle sticks
-facts documented without judgment or opinion
-should not be referred to in client's medical record
SOAP - correct answer subjective, objective, assessment, plan
PIE - correct answer problem, intervention, evaluation
DAR - correct answer (focus charting) Data, Action, Response
Privacy rule of HIPAA - correct answer -protects all individually identifiable health
information held or transmitted by a hospital (or other covered entity/business
associate) in any form of media.
-privacy rule call this information protected health information (PHI)
Hand Hygiene (Hand Washing) - correct answer -Lather all surfaces (wrists, hands, &
fingers), creating friction, for at least 20 seconds.
-Keep hands lower than elbows & fingertips down
-Rinse all surfaces (wrists, hands, & fingers), keeping hands lower than elbows &
fingertips down
two minute hand wash - correct answer must be done when hands are visibly soiled.
