NURS 201 UNIT 1 ATI QUESTIONS WITH ACCURATE
ANSWERS
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?
A) Immunization data
B) Record of client health care payments
C) Complete medical information for household members
D) Facility policies correct answer A: The nurse should include that a health record
contains any information that could influence a client's health, such as
immunization status. Other information includes medications, allergies, and
demographic data.
A charge nurse is reviewing characteristics of electronic documentation with staff
at a provider's office. Which of the following characteristics should the nurse plan
to include? (Select all that apply)
A) Reduces medical errors
B) Improves listening skills among interdisciplinary team members
C) Less convenient than paper-based charting
D) Makes client medical history more easily available
E) Increases accuracy of coding procedures correct answer A: The charge nurse
should inform the staff that electronic documentation systems can help reduce
medical errors.
D: The charge nurse should include that electronic records help to make client
information readily available to health care professionals.
E: The charge nurse should inform the staff that electronic records can lead to
more reliable coding and billing for client conditions.
,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?
A) The client states, "I've had abdominal pain for the past 3 days."
B) The client reports consuming about 1,500 mL of water per day.
C) Rebound tenderness noted in RLQ of the abdomen.
D) Recommend client referral to a registered dietitian. correct answer C:
Objective data is information the nurse gathers when collecting data about the
client, such as through physical assessment or diagnostic testing.
A client tells a nurse that they feel their HIPAA privacy has been violated and
wants to file a formal complaint with someone other than the medical facility.
Through which of the following agencies should the nurse instruct the client to
file the complaint?
A) Occupational Safety and Health Administration (OSHA)
B) The Joint Commission
C) Office for Civil Rights (OCR)
D) Privacy and Civil Liberties Office correct answer C: The OCR investigates
complaints by clients and other involved individuals related to the HIPAA Privacy
Rule. If the client wants to file a complaint to someone in the medical facility, the
nurse should arrange for the client to talk to the facility's Privacy Officer
A group of nurses on a clinical unit are planning to research the incidence of falls
among clients following joint replacement surgery. Which of the following actions
should the nurses take to ensure the study complies with the HIPAA Privacy Rule?
A) Contact the medical record department to obtain permission to access clients'
charts
, B) Submit their proposal to the institutional review board for review and describe
how they will de-identify client information
C) Notify the clients who will be included in the study to submit a written request
if they choose not to participate
D) Obtain permission from the risk management department to gain access to
incident reports that were filed due to client falls correct answer B: Research
using client records can be done if client information id de-identified. It is the
responsibility of institutional review boards to determine if a study meets
criterion
A newly hired nurse is reviewing information about the HIPAA Privacy Rule during
facility orientation. Which of the following statements by the nurse indicates an
understanding of the Privacy Rule?
A) "Clients do not have the right to read their charts"
B) "I can read the charts of other clients on my floor"
C) "I will expect a list of clients and their admitting diagnoses to be posted on my
unit"
D) I can give information about a client over the phone if the client give
permission" correct answer D: Information about a client can be given over the
phone if the client has granted permission for the person to receive information.
Many facilities have implemented an access code system that requires the person
asking for information to provide the code
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?
A) Charting by exception
B) Subjective, objective, assessment, plan format
ANSWERS
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?
A) Immunization data
B) Record of client health care payments
C) Complete medical information for household members
D) Facility policies correct answer A: The nurse should include that a health record
contains any information that could influence a client's health, such as
immunization status. Other information includes medications, allergies, and
demographic data.
A charge nurse is reviewing characteristics of electronic documentation with staff
at a provider's office. Which of the following characteristics should the nurse plan
to include? (Select all that apply)
A) Reduces medical errors
B) Improves listening skills among interdisciplinary team members
C) Less convenient than paper-based charting
D) Makes client medical history more easily available
E) Increases accuracy of coding procedures correct answer A: The charge nurse
should inform the staff that electronic documentation systems can help reduce
medical errors.
D: The charge nurse should include that electronic records help to make client
information readily available to health care professionals.
E: The charge nurse should inform the staff that electronic records can lead to
more reliable coding and billing for client conditions.
,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?
A) The client states, "I've had abdominal pain for the past 3 days."
B) The client reports consuming about 1,500 mL of water per day.
C) Rebound tenderness noted in RLQ of the abdomen.
D) Recommend client referral to a registered dietitian. correct answer C:
Objective data is information the nurse gathers when collecting data about the
client, such as through physical assessment or diagnostic testing.
A client tells a nurse that they feel their HIPAA privacy has been violated and
wants to file a formal complaint with someone other than the medical facility.
Through which of the following agencies should the nurse instruct the client to
file the complaint?
A) Occupational Safety and Health Administration (OSHA)
B) The Joint Commission
C) Office for Civil Rights (OCR)
D) Privacy and Civil Liberties Office correct answer C: The OCR investigates
complaints by clients and other involved individuals related to the HIPAA Privacy
Rule. If the client wants to file a complaint to someone in the medical facility, the
nurse should arrange for the client to talk to the facility's Privacy Officer
A group of nurses on a clinical unit are planning to research the incidence of falls
among clients following joint replacement surgery. Which of the following actions
should the nurses take to ensure the study complies with the HIPAA Privacy Rule?
A) Contact the medical record department to obtain permission to access clients'
charts
, B) Submit their proposal to the institutional review board for review and describe
how they will de-identify client information
C) Notify the clients who will be included in the study to submit a written request
if they choose not to participate
D) Obtain permission from the risk management department to gain access to
incident reports that were filed due to client falls correct answer B: Research
using client records can be done if client information id de-identified. It is the
responsibility of institutional review boards to determine if a study meets
criterion
A newly hired nurse is reviewing information about the HIPAA Privacy Rule during
facility orientation. Which of the following statements by the nurse indicates an
understanding of the Privacy Rule?
A) "Clients do not have the right to read their charts"
B) "I can read the charts of other clients on my floor"
C) "I will expect a list of clients and their admitting diagnoses to be posted on my
unit"
D) I can give information about a client over the phone if the client give
permission" correct answer D: Information about a client can be given over the
phone if the client has granted permission for the person to receive information.
Many facilities have implemented an access code system that requires the person
asking for information to provide the code
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?
A) Charting by exception
B) Subjective, objective, assessment, plan format
