ATI Comprehensive Retake 2 Study Guide 2019-Verified Questions & Answers

What can be delegated to Assistive personnel (AP)?

- ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) -

positioning - bed making - specimen collection - I&O - VS (stable clients

A nurse on a med surge unit has recieved change of shift report and will care for 4 clients.

Which of the following clients needs will the nurse assign to an AP?

A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia

B. Reinforcing teaching with a client who is learning to walk with 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

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

Which of the following info should the nurse share with the AP?

Select all:

A. the roommate is up independently

B. The client ambulates with his slippers on over his antiembolic stockings

C. The client uses a front wheeled walker when ambulating

D. The client had pain meds 30 minutes ago

E. The client is allergic to codeine

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

B

C

D

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

following assignments should the LPN question?

A. Assisting a client who is 24 hr 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

A nurse is preparing an inservice 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

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

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

staff member should the nurse assign the client?

A. Charge nurse

B. RN

ATI Comprehensive Retake 2 Study Guide 2019

C. LVN

D. AP

B

What is the study of conduct and character?

Ethics

What are the values and beliefs that guide behavior and decision making?

Morals

What is the right to make ones own personal decisions, even tho those decisions might not be

in the persons best interest

Autonomy

What are positive actions to help others

Beneficience

What is an agreement to keep promises

Fidelity

What is fairness in care delivery and use of resources

Justice

What is avoidance of harm or injury

Non-maleficence

A nurse is caring for a client who decides not to have surgery despite significant blockages in his

coronary arteries. The nurse understands that this clients choice is an example of what

principles?

A. Fidelity

B. Autonomy

C. Justice

D. Nonmalificience

A

A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands

that this aspect of care delivery is an example of which of the following ethical principles?

A. Fidelity

B. Autonomy

C. Justice

D. Beneficience

D

A nurse is instructing a group of nursing students about the responsibilities involved with organ

donation and procurement. When the nurse explains that all clients waiting for a kidney

transplant have to meet the same qualifications, the students should understand that this

aspect of care delivery is an example of which ethical principle

A. Fidelity

B. Autonomy

C. Justice

D. Nonmaleficence

C

A nurse questions a med prescription as too extreme and light of the clients advanced age and

unstable status. The nurse understands that this action is an example of which ethical principle

A. Fidelity

B. Autonomy

C. Justice

D. Nonmalificence

D

Which of the following situations can be identified as an ethical dilemma?

A. A nurse on a med surge unit demonstrates signs of chemical impairment

B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she

will restrain him

C. A family has conflicting feelings about the initiation of enteral tube feedings of their father

who is terminally ill

D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney

form

C

Most managers can be categorized as

authoritative, democratic, and laissez faire

makes decisions of the group

motivates by coercion

communication occurs down the chain of command

Work output by the staff is usually high-good for crisis situations and bureaucratic settings

Authoritative

includes the group when decisions are made

Motivates by supporting star achievements

Communication occurs up and down the chain of command

Work output by staff is usually of good quality-good when cooperation and collaboration is

necessary

Democratic

makes very few decisions and does little planning

motivation is largely the responsibility of individuals staff members

Communication occurs up and down the chain of command and between group members

Work output is low unless an informal leader evolves from the group

*the use of any of these styles may be appropriate depending on the situation

Laissez faire

The nurse should consider the hierarchy of human needs when prioritizing interventions, which

are?

- Physiological needs first (oxygen, shelter, food)

- Safety & security needs (physical safety)

- Love and belonging

- Self esteem

- Self actualization

The ABC framework identifies, in order, the three basic needs for sustaining life

Airway

Breathing

Circulation

Nurses must follow what code of standards in delegating and assigning tasks

ANA codes of standards

What values would a nurse possess to be a client advocate?

- caring

- autonomy

- respect

- empowerment

What do the nurse need to keep in mind about the client when being their advocate?

Client's religion & culture

When should planning discharge process begin?

a. at time of admission

b. 2 days after client is admitted

c. whenever the nurse has the time to do planning

d. when the physician has the discharge order

A

What is an interdisciplinary team?

A group of health care professionals from different disciplines

Fill in the blank:

1. _______ is used by interdisciplinary team to make health care decisions about clients with

multiple problems. 2. ________, which may take place at team meetings, allows the

achievement of results that the participants would be incapable of accomplishing if working

alone.

1 & 2 = collaboration

What is the nurse's contribution to an interdisciplinary team?

- knowledge of nursing care & its management

- a holistic understanding of the client, her/his healthcare needs & healthcare systems.

A four-month-old infant is admitted to the pediatric intensive care unit

with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse

observes nuchal rigidity. Which assessment finding would indicate an

increase in intracranial pressure?

1. Positive Babinski.

2. High-pitched cry.

3. Bulging posterior fontanelle.

4. Pinpoint pupils.

2

A client is receiving total parenteral nutrition (TPN). To determine the

client's tolerance of this treatment, the nurse should assess for which of the

following?

1. A significant increase in pulse rate.

2. A decrease in diastolic blood pressure.

3. Temperature in excess of 98.6°F (37°C).

4. Urine output of at least 30 cc per hour.

4

The client is exhibiting symptoms of myxedema. The nursing

assessment should reveal

1. increased pulse rate.

2. decreased temperature.

3. fine tremors.

4. increased radioactive iodine uptake level.

2

A nonstress test is scheduled for a client at 34-weeks gestation who

developed hypertension, periorbital edema, and proteinuria. Which of the

following nursing actions should be included in the care plan in order to

BEST prepare the client for the diagnostic test?

1. Start an intravenous line for an oxytocin infusion.

2. Obtain a signed consent prior to the procedure.

3. Instruct client to push a button when she feels fetal movement.

4. Attach a spiral electrode to the fetal head.

3

Which of the following nursing interventions is MOST important for a

45-year-old woman with rheumatoid arthritis?

1. Provide support to flexed joints with pillows and pads.

2. Position her on her abdomen several times a day.

3. Massage the inflamed joints with creams and oils.

4. Assist her with heat application and ROM exercises.

4

The nurse is caring for a young adult admitted to the hospital with a

severe head injury. The nurse should position the patient

1. with his neck in a midline position and the head of the bed elevated 30°.

2. side-lying with his head extended and the bed flat.

3. in high Fowler's position with his head maintained in a neutral position.

4. in semi-Fowler's position with his head turned to the side.

1

The nurse is teaching a 40-year-old man diagnosed with a lower motor

neuron disorder to perform intermittent self-catheterization at home. The

nurse should instruct the client to

1. use a new sterile catheter each time he performs a catheterization.

2. perform the Valsalva maneuver(holding breath and bearing down) before doing the

catheterization.

3. perform the catheterization procedure every 8 hours.

4. limit his fluid intake to reduce the number of times a catheterization is needed.

2

A client is being discharged with sublingual nitroglycerin (Nitrostat).

The client should be cautioned by the nurse to

1. take the medication five minutes after the pain has started.

2. stop taking the medication if a stinging sensation is absent.

3. take the medication on an empty stomach.

4. avoid abrupt changes in posture.

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