ATI Fundamentals Proctored Exam 2019 | Complete Document | 100% Correct

ATI FUNDAMENTALS PROCTORED EXAM

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Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? Yes.

A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which

of the following client's needs may the nurse assign to a assistive personnel (AP)?

A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia

B. Reinforcing teaching w/a client who is learning to walk using a quad cane

C. Reapplying a condom catheter for a client who has urinary incontinence

D. Applying a sterile dressing to a pressure ulcer

C. Reapplying a condom catheter for a client who has urinary incontinence

Rationale: The application of a condom catheter is a noninvasive, routine procedure that the

nurse may delegate to the AP

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP.

Which of the following information should the nurse share with the AP? Select All.

A. The roommate is up independently.

B. The client ambulates w/his slippers on over his antiembolic stockings

C. The client uses a front-wheeled walker when ambulating

D. The client had pain medication 30 min ago

E. The client is allergic to codeine

F. The client ate 50% of his breakfast this morning

B, C, D

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An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the

following assignments should the LPN question?

A. Assisting a client who is 24hr postop to use an incentive spirometer

B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift

C. Providing nasopharyngeal suctioning for a client who has pneumonia

D. Replacing the cartridge and tubing on a PCA pump

D. Replacing the cartridge and tubing on a PCA pump

Rationale: The RN is responsible for the PCA pump

A nurse is preparing an in-service program about delegation. Which of the following elements

should she identify when presenting the 5 rights of delegation? Select all.

A. Right client

B. Right supervision/evaluation

C. Right direction/communication

D. Right time

E. Right circumstances

B, C, E

Rational: A and D are rights of medication administration

A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A

client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which

staff member should the nurse assign to this client?

A. Charge nurse

B. RN

C. LPN

D. AP

B. RN

Rational: A client returning from surgery requires assessment and establishment of a plan of

care. RNs are responsible for this, especially if the client is potentially unstable.

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A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him

she will put a diaper on him if he does not use the urinal more carefully next time. Which of the

following torts is the AP committing?

A. Assault

B. Battery

C. False imprisonment

D. Invasion of privacy

A. Assault

Rational: By threatening the client, the AP is committing assault.

An adult client who is competent tells the nurse that he is thinking about leaving the hospital

against medical advice. The nurse believes that this is not in the client's best interest, so she

administers a PRN sedative med that the client has not requested along w/his usual meds.

Which of the following tort has the nurse committed?

A. Assault

B. False imprisonment

C. Negligence

D. Breach of confidentiality

B. False imprisonment

Rational: The nurse gave the med as a chemical restraint to keep the client from leaving the

facility against medical advice. The client did not consent.

A client who will undergo neurosurgery the following week tells the nurse in the surgeon's

office that he will prepare his advance directives before he goes to the hospital. Which of the

following statements by the client indicates to the nurse that he understands advance

directives?

A. "I'd rather have my brother make decisions for me, but I know it has to be my wife."

B. "I know they won't go ahead w/the surgery unless I prepare these forms."

C. "I plan to write that I don't want them to keep me on a breathing machine."

D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."

C. "I plan to write that I don't want them to keep me on a breathing machine."

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Rational: The client has the right to decide and specify which medical procedures he wants

when a life-threatening situation arrives

A client is about to undergo an elective surgical procedure. Which of the following actions are

appropriate for the nurse who is providing pre-op care regarding informed consent? Select all.

A. Make sure the surgeon obtained the client's consent

B. Witness the client's signature on the consent form

C. Explain the risks and benefits of the procedure

D. Describe the consequences of choosing not to have the surgery E. Tell the client about

alternatives to having the surgery

A, B

Rational: The rest of the choices are the surgeon's responsibility, not the nurse

A nurse has noticed several occasions in the past week when another nurse on the unit seemed

drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in

the break room when she was not on break. Which of the following actions should the nurse

take?

A. Remind the nurse that safe client care is a priority on the unit

B. Ask others on the team whether they have observed the same behavior

C. Report observations to the nurse manager on the unit

D. Conclude that her coworker's fatigue is not her problem to solve

C. Report observations to the nurse manager on the unit

Rational: Any nurse who notices behavior that could possibly jeopardize client care or

indicate a substance abuse problem has a duty to report the situation immediately to the

nurse manager

A nurse is preparing info for a change-of-shift report. Which of the following info should the

nurse include in the report?

A. The client's input & output for the shift

B. The client's BP from the previous day

C. A bone scan that is scheduled for today

D. The med routine from the med administration record

C. A bone scan that is scheduled for today

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Rational: This is important because the nurse might have to modify the client's care to

accommodate them leaving the unit

A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but

I got myself back up & into my chair." How should the nurse document this in the client's chart?

A. The client fell in the shower.

B. The client states he fell in the shower & was able to get himself back into his chair

C. The nurse should not document this info because she did not witness the fall

D. The client fell in the shower & is now resting comfortably

B. The nurse should not document this info because she did not witness the fall

Rational: By writing what the client states, the info is subjective data

A nursing instructor is reviewing documentation w/a group of nursing students. Which of the

following legal guidelines should they follow when documenting a client's record? Select all that

apply

A. Cover errors w/correction fluid, & write in the correct info

B. Put the date & time on all entries

C. Document objective data, leaving out opinions

D. Use as many abbreviations as possible

E. Wait until the end of the shift to document

B, C

The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to

ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the

client is supine in bed. The nurse telephoned the physical therapist about the difficulties

containing the drainage from the fistula, so the therapist didn't ambulate the client today. The

client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food

on her tray. The wound care nurse confirmed that she will see the client later today. The client

states she feels frustrated at not having physical therapy, but the nurse thinks the client

welcomed having a day to rest. Which of the following information should the nurse include in

the change-of-shift report? Select all that apply.

A. The physical therapist didn't ambulate the client today

B. The skin barrier's seal stays on in bed but loosens when the client stands.

C. The client seemed to welcome having a "day off" from physical therapy

D. The wound care nurse will see the client later today

E. The client ate all the food on her lunch tray

A, B, D

A nurse is receiving a provider's prescription by telephone for morphine for a client who is

reporting moderate to severe pain. Which of the following nursing actions are appropriate?

Select all that apply.

A. Repeat the details of the prescription back to the provider

B. Have another nurse listen to the telephone prescription

C. Obtain the prescriber's signature on the prescription within 24hrs

D. Decline the verbal prescription because it is not an emergency situation

E. Tell the charge nurse that the provider has prescribed morphine by telephone

A, B, C

A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He

states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To

which of the following members of the health care team should the nurse refer him?

A. Registered dietitian

B. Occupational therapist

C. Physical therapist

D. Social worker

D. social worker

Rational: A social worker can make arrangements for a meal delivery service to provide

nutritious meals daily, or recommend a congregate meal site near the client's home

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A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use

adaptive devices. The nurse caring for the client should initiate a referral w/which of the

following members of the inter-professional care team?

A. Social worker

B. Certified nursing assistant

C. Registered dietitian

D. Occupational therapist

E. Registered dietitian

D. Occupational therapist

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