lOMoAR cPSD| 16310474
RN ATI MED SURG HESI 2025/2026
WITH 99 VERIFIED QUESTIONS With
Complete Updated Solutions
With Rationales Graded A+
,The nurse is providing care for a patient who is unhappy with the health care
provider's care. The patient signs the Against Medical Advice (AMA) form and
leaves the hospital against medical advice. What should the nurse include in the
documentation of this event in the patient's medical record or on the AMA form?
Select all that apply.
1. Documentation that the patient was informed that he or she cannot come back
to the hospital
2. Documentation that the patient was informed that he or she was leaving
against medical advice
3. Documentation that the risks of leaving against medical advice were explained
to the patient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been completed -
ANSWER2,3,4 Ra 琀椀 onale 1: It should be clearly documented that the
patientwas advised and understands that he or she can come back. Ra 琀椀
onale 2: It should be clearly documented in the pa 琀椀 ent'srecord and on the
AMA form that the patientwas advised that he or she was leaving against
medical advice. Ra 琀椀 onale 3: It should be clearly documented that the
patientunderstandsthe risks of leaving against medical advice. Ra 琀椀 onale 4:
The AMA form includes the name of the person accompanying the patientand
any discharge instruc 琀椀 ons given. Ra 琀椀 onale 5: Facility policy may
require that an incident report be completed, but it must not be referenced in
the chart. The pa 琀椀 ent'srecord is a legal document, so the nurse should
never document that he or she 昀椀 led an incident report.
, lOMoAR cPSD| 16310474
A nurse documents this statement in a pa 琀椀 ent's medical record: "2/25/-,
2235. At
2015 patientawoke suddenly and complained of shortness of air. Pulse oximetry
reading was 82% on room air and audible wheezes could be heard." This
documentationmeets which documentationguidelines? SATA
1. Documentationis 琀椀 mely
2. Documentationis concise
3. Documentationis objec 琀椀 ve
4. Documentationincludes date and 琀椀 me of entry
5. Documentationis complete and accurate - ANSWER-2,3,4,5 Ra 琀椀 onale 1:
The nurse should document as soon as possible a 昀琀 er an observa 琀椀 on
is made or care is provided. The entry was made in the pa 琀椀 ent's medical
record at least 2 hours a 昀琀 er the patientcomplaint and should be labeled
late entry. Ra 琀椀 onale 2: This entry describes the situa 琀椀 on fully but is
concise. Ra 琀椀 onale 3: The nurse describesfactual events that can be seen,
heard, smelled, or touched. It is important to be objec 琀椀 ve and avoid vague
statements that are subjec 琀椀 ve.
Ra 琀椀 onale 4: Both the date and the 琀椀 me of the entry are documented. Ra
琀椀 onale 5: The nurse should document only facts: what he or she can see,
hear, and do.
A nurse documents the following in a pa 琀椀 ent's medical record: "2/1/ , 1500.
Patientappears weak and faint. Pa 琀椀 ent's skin is moist and cool, vomited
bright red blood with clots. Health care provider no 琀椀昀椀 ed and order
received to give 2 u of packed red blood cells if stat Hgb is < 8.0. Pain medica 琀椀
on will be given." This documentationmeets which documentationprinciple?
1. Document objec 琀椀 vely.
, 2. Do not document procedures in advance.
3. Use approved abbrevia 琀椀 ons.
4. Document changes in patientcondi 琀椀 on - ANSWER-4
In general, employers as well as state, federal, and professional standards require
documentationto include ini 琀椀 al and ongoing assessments, any change in the
pa 琀椀 ent's condi 琀椀 on, therapies given and patientresponse,
patientteaching, and relevant statements by the pa 琀椀 ent.
A nursing unit has changed its documentationsystem to documen 琀椀 ng by
excep 琀椀 on. How will this system save 琀椀 me?
1. It eliminates lengthy or repe 琀椀琀椀 ve documenta 琀椀 on.
2. It allows 昀氀 exibility and descrip 琀椀 on in the documenta 琀椀 on.
3. It allows the reader to easily locate informa 琀椀 on about a speci 昀椀 c
problem.
4. It allows for quick and easy retrieval of informa 琀椀 on. - ANSWER-1 Ra 琀椀
onale 1: Documen 琀椀 ng by excep 琀椀 on eliminates lengthy or repe 琀椀
琀椀 ve documenta 琀椀 on. Ra 琀椀 onale 2: Flexible and descrip 琀椀 ve
documentationis an advantage of the narra 琀椀 ve system. Ra 琀椀 onale 3:
PIE char 琀椀 ng allows easy loca 琀椀 on of informa 琀椀 on about a speci 昀
椀 c problem. Ra 琀椀 onale 4: The electronic health record allowsfor quick
and easy retrieval of informa 琀椀 on.
A hospital is considering changing its documentationsystem to reduce the number
of medica 琀椀 on errors. Which system should the hospital inves 琀椀 gate?
RN ATI MED SURG HESI 2025/2026
WITH 99 VERIFIED QUESTIONS With
Complete Updated Solutions
With Rationales Graded A+
,The nurse is providing care for a patient who is unhappy with the health care
provider's care. The patient signs the Against Medical Advice (AMA) form and
leaves the hospital against medical advice. What should the nurse include in the
documentation of this event in the patient's medical record or on the AMA form?
Select all that apply.
1. Documentation that the patient was informed that he or she cannot come back
to the hospital
2. Documentation that the patient was informed that he or she was leaving
against medical advice
3. Documentation that the risks of leaving against medical advice were explained
to the patient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been completed -
ANSWER2,3,4 Ra 琀椀 onale 1: It should be clearly documented that the
patientwas advised and understands that he or she can come back. Ra 琀椀
onale 2: It should be clearly documented in the pa 琀椀 ent'srecord and on the
AMA form that the patientwas advised that he or she was leaving against
medical advice. Ra 琀椀 onale 3: It should be clearly documented that the
patientunderstandsthe risks of leaving against medical advice. Ra 琀椀 onale 4:
The AMA form includes the name of the person accompanying the patientand
any discharge instruc 琀椀 ons given. Ra 琀椀 onale 5: Facility policy may
require that an incident report be completed, but it must not be referenced in
the chart. The pa 琀椀 ent'srecord is a legal document, so the nurse should
never document that he or she 昀椀 led an incident report.
, lOMoAR cPSD| 16310474
A nurse documents this statement in a pa 琀椀 ent's medical record: "2/25/-,
2235. At
2015 patientawoke suddenly and complained of shortness of air. Pulse oximetry
reading was 82% on room air and audible wheezes could be heard." This
documentationmeets which documentationguidelines? SATA
1. Documentationis 琀椀 mely
2. Documentationis concise
3. Documentationis objec 琀椀 ve
4. Documentationincludes date and 琀椀 me of entry
5. Documentationis complete and accurate - ANSWER-2,3,4,5 Ra 琀椀 onale 1:
The nurse should document as soon as possible a 昀琀 er an observa 琀椀 on
is made or care is provided. The entry was made in the pa 琀椀 ent's medical
record at least 2 hours a 昀琀 er the patientcomplaint and should be labeled
late entry. Ra 琀椀 onale 2: This entry describes the situa 琀椀 on fully but is
concise. Ra 琀椀 onale 3: The nurse describesfactual events that can be seen,
heard, smelled, or touched. It is important to be objec 琀椀 ve and avoid vague
statements that are subjec 琀椀 ve.
Ra 琀椀 onale 4: Both the date and the 琀椀 me of the entry are documented. Ra
琀椀 onale 5: The nurse should document only facts: what he or she can see,
hear, and do.
A nurse documents the following in a pa 琀椀 ent's medical record: "2/1/ , 1500.
Patientappears weak and faint. Pa 琀椀 ent's skin is moist and cool, vomited
bright red blood with clots. Health care provider no 琀椀昀椀 ed and order
received to give 2 u of packed red blood cells if stat Hgb is < 8.0. Pain medica 琀椀
on will be given." This documentationmeets which documentationprinciple?
1. Document objec 琀椀 vely.
, 2. Do not document procedures in advance.
3. Use approved abbrevia 琀椀 ons.
4. Document changes in patientcondi 琀椀 on - ANSWER-4
In general, employers as well as state, federal, and professional standards require
documentationto include ini 琀椀 al and ongoing assessments, any change in the
pa 琀椀 ent's condi 琀椀 on, therapies given and patientresponse,
patientteaching, and relevant statements by the pa 琀椀 ent.
A nursing unit has changed its documentationsystem to documen 琀椀 ng by
excep 琀椀 on. How will this system save 琀椀 me?
1. It eliminates lengthy or repe 琀椀琀椀 ve documenta 琀椀 on.
2. It allows 昀氀 exibility and descrip 琀椀 on in the documenta 琀椀 on.
3. It allows the reader to easily locate informa 琀椀 on about a speci 昀椀 c
problem.
4. It allows for quick and easy retrieval of informa 琀椀 on. - ANSWER-1 Ra 琀椀
onale 1: Documen 琀椀 ng by excep 琀椀 on eliminates lengthy or repe 琀椀
琀椀 ve documenta 琀椀 on. Ra 琀椀 onale 2: Flexible and descrip 琀椀 ve
documentationis an advantage of the narra 琀椀 ve system. Ra 琀椀 onale 3:
PIE char 琀椀 ng allows easy loca 琀椀 on of informa 琀椀 on about a speci 昀
椀 c problem. Ra 琀椀 onale 4: The electronic health record allowsfor quick
and easy retrieval of informa 琀椀 on.
A hospital is considering changing its documentationsystem to reduce the number
of medica 琀椀 on errors. Which system should the hospital inves 琀椀 gate?
