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Bundle for ATI SCOPE exam 100% correct
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NUR 204 ATI Management of Care Ch. 1-9 questions answered 100% correct
A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implement... [Show More] ed? "I will begin upon the client's admission to the facility." A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the nurse acting as an advocate? An older adult client who has no family and is uncertain about moving to assisted living A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first? A client who was admitted for chest pain and is reporting a new onset of indigestion A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sound in his temporomandibular joint. Based on these findings, to which of the following providers should the nurse request a referral for the client? Oral surgeon A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? Obtain vital signs for both clients A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity? Assigning tasks to an assistive personnel (AP) A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)? Scheduling a diagnostic study for a client A nurse is transcribing a client's medication prescriptions and is having difficulty reading a written prescription by the provider. Which of the following nursing actions should the nurse take? Contact the provider to clarify the prescription A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality? Reporting laboratory findings to a member of the client's family A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team? Occupational therapist A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? Collect and organize client data A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? -Decreased gastric motility -Decreased skin elasticity -Increased pain threshold A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the following information should the nurse include? The nurse may serve as a witness to informed consent for organ donation A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide? This service began with client's admission to the hospital A nurse is orienting a newly licensed nurse about receiving telephone prescriptions. Which of the following statements by the newly licensed nurse should indicate a need for further teaching? "Telephone prescriptions are transcribed into the nurse's notes." A nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. The nurse should plan to consult with which of the following health care team members to help educate the client? Respiratory therapist A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? Code status A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take? Notify the surgeon that the client wishes to withdraw informed consent for the procedure [Show Less]
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Professional Nursing Practice questions and answers |graded A+
In what role does a nurse assess resources, strengths and weaknesses, coping behaviors, and the environment to help the client regain health to a maximum l... [Show More] evel of independent functioning? Care provider A nurse acting to accomplish goals in an efficient manner with other people is fulfilling which of the following roles? Manager Which of the following makes it acceptable to report confidential client information abuse, neglect or exploiation is suspected? Health Insurance Portability and Accountability Act Which of the following is an example of an unintentional tort? Negligence Which of the following actions represents the professional value of altruism? A nurse mentoring a colleague in professional growth. Which of the following defines nursing's scope of practice in each state? Nurse Practice Acts Which of the following professional associations established the Code of Ethics, Social Policy Statement, and Scope and Standards of Practice? American Nurses Association Participation in health policy development and the political process is a significant part of which of the following nursing roles? Advocate When obtaining written consent for a procedure to be performed by someone else, the nurse's signature confirms which if the following? (Select all that apply.) The client appears competent to agree to the procedure. The client consents voluntarily to the procedure. A nurse is telling the truth, keeping promises and doing no harm while caring a client who is experiencing conflict with this family. Which of the following is the nurse demonstrating? Primary commitment to the client. [Show Less]
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ATI vital post test questions and answers 100% correct
A nurse is taking an adult client's temperature rectally. Which of of the following actions should the nurse take? Insert the prob about 1.27 cm (0.5 in) ... [Show More] into the client's anus A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to? It might not follow with the fitfh Korotkoff sound. A nurse is preparing to auscultate a client's apical pulse a the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope? Over the fifth intercostal space at the left midclaviclular line. A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39 celsius (102 degrees f). Which of the following other vital signs should the nurse expect? Elevated pulse rate A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration. Observe the degree of the chest-wall movement during inspiration and expiration. A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider? Respirations 30/min A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting? Pulse pressure A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs? When the semilunar valves close A nurse is preparing to obtain a clients blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately? Use a cuff of the appropriate size for the client A nurse is assessing a client's respiration. Which of the following actions should the nurse take? Elevate the head of the clients bed 45 degree to 60 degree. A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take? Place the probe in the posterior lingual pocket lateral to there midline. A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take? Observe the clients chest movements while appearing to assess their pulse. A nurse is preparing to use a tympanic thermometer to acquire a clients temperature. Which of the following actions actions should the nurse take to ensure an accurate reading? Pull the pinna back and upward gently A nurse is preparing to measure a clients vital signs. The nurse should identify that which of the following factors will affect the methods that are used? 1. BMI of 35 2. Stuffy nose 3. irregular hearth rate 4. mastectomy 2 years ago [Show Less]
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Management ATI #1 Remediation, questions and answers |graded A+
Legal responsibilities: continuity of care The purpose of reporting is to provide continuity of care and enhance communication among all team members who ... [Show More] provide care to the same clients, thus promoting client safety. Nurses should use the formal chain of command to verbalize concerns related to assignment in light of current legal scope of practice, job description, and are of competence. Nurses should refuse to practice beyond the legal scope of practice or outside of their areas of competence regardless of reason (staffing shortage, lack of appropriate personnel). ATI Ch 5 Information technology: change-of-shift report The purpose of reporting is to provide continuity of care and enhance communication among all team members who provide care to the same clients, thus promoting client safety. Nurses should conduct reporting in a confidential manner. An effective report should include significant objective information about the client's health problems, proceed in a logical sequence, include no gossip or personal opinion, and relate recent changes in medications, treatments, procedures, and the discharge plan. ATI Ch 5 Admissions, transfers, and discharge: initiating discharge planning Discharge planning is an inter professional process that starts at admission. Nurses conduct discharge planning with clients and families for optimal results. Nurses use the nursing process as a guide to plan teaching and intervention for clients during discharge. The nurse should assess whether the client will be able to return to his previous residence. ATI Ch 9 Ethical responsibilities: the principle of veracity Veracity is a commitment to tell the truth. Ethical dilemmas are problems that involve more than one choice and stem from differences in the values and beliefs of the decision makers. Nurses must apply ethical theory and decision-making to ethical problems. Ethical decision-making is a process that requires striking a balance between science and morality. ATI Ch 3 Legal responsibilities: who can give informed consent Informed consent is a legal process by which a client or the client's legally appointed designee has given written permission for a procedure or treatment. Consent is informed when a provider explains and the client understands the reason the client needs the treatment or procedure, how the treatment/procedure will benefit the client, risk involved if the client chooses to receive the treatment or procedure, and other options to treat the problem, including not treating the problem. A competent adult must sign the form for informed consent. Medical interpreters might be necessary. Emancipated minors (minors who are independent or married) may consent. Mature adolescents may sign assent. ATI Ch 4 Airway management: best practice for oxygen therapy Provide oxygen therapy at the lowest liter flow that will correct hypoxemia. Assess/monitor hypoxemia and hypercarbia (elevated CO2): restlessness, hypertension, and headache. Encourage turning, coughing, deep breathing, and the use of incentive spirometry and suctioning. Make sure all electric machinery (monitors, suction machines) is grounded. ATI Ch 53 Airway management: use of home oxygen Don't use volatile, flammable materials (alcohol, acetone). Don't wear synthetic or wool fabrics. Ensure that all electric devices (razors, hearing aids, radios) are working well. Do not smoke. Have fire extinguishers easily accessible. ATI Ch 53 Infection control: precautions for shigella Shigella's portal of exit (means of leaving the host) is the GI tract. Standard precautions (tier one) are used for shigella. This includes hand hygiene. This also includes masks, eye protection, and face shields when care might cause splashing or spraying of body fluids. The client doesn't need a private room. ATI Ch 11 Infection control: planning a protective environment A protective environment protect clients who are immunocompromised, such as those who have had an allogenic hematopoietic stem cell transplant. A protective environment requires a private room, positive airflow with 12 or more air exchanges/hr, HEPA filtration for incoming air, and a mask for the client to wear when out of their room. ATI Ch 11 Mobility and immobility: applying a sequential compression device Use sequential compression devices to prevent thrombus formation. Increase activity as soon as possible by dangling feet on side of bed or transferring to a chair. Teach range of motion and antiembolic exercises such as ankle pumps, foot circles, and knee flexion. ATI Ch 40 Pain management: priority action for dressing changes Pain medication should be given prior to dressing changes if client reports that dressing changes are painful. Infants, children, older adults, and clients who have substance use disorder are at risk for under treatment of pain. Nonpharmacological pain management strategies include heat, cold, ambulation, deep breathing, acupuncture, and elevation of edematous extremities. ATI Ch 41 [Show Less]
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NU 101: ATI Practice Assessment 1, questions and answers 100% correct
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication re... [Show More] aches the inner ear? Press gently on the tragus of the client's ear A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? A client who has an IV infusion pump receives an additional 250 mL of IV fluid. A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? Reassure the client that this is an expected response to grief. nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? Flush the tube with 15 mL of sterile water -Each medication should be dissolved in at least 30 mL of warm, sterile water -medications should be drawn up separately - if the nurse encounters resistance when adm. meds, he should stop and contact the provider A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? Stand close to the cabinet when lifting it. DO NOT bend at the waist, keep his feet close together, or use his back muscles for lifting Good Ergonomics p 1043-1044 (Taylor) A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? *** a. "I'm having mild pain" b. "The pain is like a dull ache in my stomach" c. "I notice the pain gets worse after I eat" d. "The pain makes me feel nauseous" "The pain is like a dull ache in my stomach" -"I'm having mild pain" (describes the sevarity of the pain. The nurse should use a pain scale to make this more accurate) -"I notice the pain gets worse after I eat" (this is a factor that aggravates the pain) -"The pain makes me feel nauseous" (manifestation of the pain) A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? Potassium 5.4mEq/L A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? The client holds the cane on the stronger side of the body Proceeding with Ambulation: 1. the patient stands with weight evenly distributed between the feet and the cane 2. The cane is held on the patients stronger side and is advanced 4-12in (10-30cm) 3. Supporting weight on the stronger leg, advance the weaker leg forward, parallel with the cane 4. Supporting weight on the weaker leg, advance the stronger leg forward, ahead of the cane 5. The weaker leg is moved forward until even with the stronger leg along with advancement of the cane pg 1078 (Taylor) A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? Semi-fowler's A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? Have family members wear a gown and gloves when visiting. See page 546 (Taylor) A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? Ask another nurse to observe the medication wastage. (locking the remaining controlled substance in the cabinet would be a violation of the Controlled Substances Act, page 760-Taylor) A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? Narrowed arterial lumen (hearing bruits on the audiotape indicates that blood flowing through the occluded or narrowed arteries Heart Sounds https://www.youtube.com/watch?v=6YY3OOPmUDA A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? Subtract the amount of irrigant used from the client's urine output. A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? Pupil clarity Visual fields Visual acuity Risk for Falls p692 (Taylor) **A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? Skin Blanching along with edema and coolness at the IV site A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? Gently shake the container of medication prior to administration. DO: Place P in high-fowlers position prior to med admin. DO NOT" a. transfer pre-packaged liquid med into a cup due to risk of altered dosing A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? a. Auscultate lung sounds b. Measure urine output c. Monitor BP readings d. Monitor serum electrolyte levels Auscultate lung sounds Why? This assessment is priority when using airway, breathing, and circulation (ABC) approach to monitor fluid-volume excess, which can be a complication of IV therapy. Moist crackles, dyspnea (difficult/labored breathing), and shortness of breath can be adverse effects. A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? Use a clock pattern to describe food on the client's plate. (allows for greater independence during meals) A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? a. Erythema on pressure points b. Lower-extremity pulse strength of 2+ c. Fluid intake of 3,000 mL per day d. A bowel movement every other day Erythema on pressure points -2+ is an expected finding -Clients should drink between 2,000-3,000mL of fluids a day -bowel movements less frequent than 3/wk indicate constipation and should be further evaluated **A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. Use a restriction bag w/ 80% O2 prior to the procedure b. Select a suction catheter that is half the size of the lumen. c. PLace the end of the suction catheter in a water-soluble lubricant d. Adjust the wall suction apparatus to a pressure of 170 mm Hg Select a suction catheter that is half the size of the lumen. (selecting a suction catheter 1/2 size prevents hypoxemia and trauma to the mucosa) Why? -100% O2 should be used - the nurse should lubricate with sterile water or 0.9% sodium irrigation to decrease trauma to the mucosa - 120 mm Hg, no higher than 150 mm hg should be used to prevent hypoxemia and trauma to the mucosa nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? Airborne airborne precautions are used for Pts whom have infections that spread via droplet nuclei, that are smaller than 5 microns (includes varicella, TB, and measles) >Droplet nuclei larger than 5 microns require DROPLET precautions (include rubella, meningococcal pneuomia, and streptococcal pharyngitis) >Contact precautions are used for infections spread via direct contact or contact with the environment (incl. vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies) > Protective Equiptment: Clients with a compromised immune system A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures would the nurse recommend? Use progressive relaxation techniques at bedtime. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take FIRST? Check the client for injuries A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? a. Smoothie b. Banannas c. Pancakes d. Fried Egg fried egg eggs that are poached or scrambled are an acceptable replacement for this item A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? "Are you able to help with your hygiene care?" A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? "I'll check the wires and cables on my TV to make sure they are in good working order." Additinal Safety Info: >visitors must smoke outside the house >use cotton materials, not woolen or synthetic materials (they can create sparks) >ensure any electrical equipment in the room is functioning properly to avoid electrical sparks >keep the tank upright and secure in its holder at all times A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take FIRST? a. Rinse the feeding bag with water between findings b. Tell the client to keep the head of the bed elevated at least 30 degrees. c. Make sure the enteral formula is at room temperature d. Wipe the top of the formula with alcohol Tell the client to keep the head of the bed elevated at least 30 degrees. *all other steps should be followed but the height of the bed is most important Administration Skill is onp1247 (Taylor) A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? Have the client stand with her arms at her side and her feet together. (Assesses balance) Romberg Test Skill p680 (Taylor) **A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make? "You should have a fecal occult blood test every year." -avg risk starts at age 50 Additional Tips: >blood-contrast barium enema every 5yrs >Colorectal cancer screenings begin at age 50. One option is colonoscopy Q10yrs > flexible sigmoidoscopy Q5yrs (Starting on p419-Taylor. See Table 19-1 on p424) A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention b. Decreased blood pressure c. Calf swelling d. Deminished bowel sounds Calf swelling Calf swelling includes swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility -bladder distention can cause urinary retention, bladder distention, can be a complication of bed rest due to a loss of muscle tone in bladder and detrusor muscles -A pt on bed rest can develop postural hypotension manifested by a drop in BP when the client moves from lying to sitting. The nurse should also assess for a increase in pulse rate and dizziness -diminished bowel sounds reflect slowed peristalsis and constipation A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? Rapid heart rate A nurse is planning an deduction session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? Allow extra time for the client to respond to questions. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? Contact precautions A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? a. a nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse b. a nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care c. a nurse asks a nurse from another unit to assist with her documentation d. a nurse discussed a client's status with the PT that's caring for the clients at their bedside c. A nurse asks a nurse from another unit to assist with her documentation. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Cleanse the wound from the center outward. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? Withhold the blood transfusion. A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? 0.3 mg [Show Less]
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Delegation (ATI Chapter 6) questions and answers 2023
A nurse on a medical‑surgical unit has received change‑of‑shift report and will care for four clients. Which of the following client's needs should t... [Show More] he nurse assign to an assistive personnel. A.Feeding a client who was admitted 24 hr ago with aspiration pneumonia B.reinforcing teaching with 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 A. it would be inappropriate to delegate the feeding of a client who has aspiration pneumonia to an ap because the client is at risk for further aspiration. B. either an rn or an pn, not an ap, may reinforce teaching. C. CORRECT: the application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to an ap. D. either an rn or an pn, not an ap, may apply a sterile dressing. RN delegation NEVER DELEGATE NURSING PROCESS LPN delegation tasks Monitoring client findings (as input to the RN's ongoing assessment of the client) • Reinforcing client teaching from a standard care plan • Performing tracheostomy care • Suctioning • Checking nasogastric tube patency • Administrating enteral feedings • Inserting a urinary catheter • Administrating medication (excluding intravenous medications in several states) AP delegation tasks • Activities of daily living (ADLs) • Bathing • Grooming • Dressing • Toileting • Ambulating • Feeding (without swallowing precautions) • Positioning • Bed making • Specimen collection • Intake and output (I&O) • Vital signs (for stable clients) A nurse manager of a medical‑surgical 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 of the following staff members should the nurse assign this client? A. Charge nurse B. rn C.practical nurse D.assistive personnel A. although the charge nurse can provide all the care this client requires in the immediate postoperative period, administrative responsibilities might prevent the close monitoring and assessment this client needs B. CORRECT: a client returning from surgery requires an rn's assessment and establishment of a plan of care, especially if the client is potentially unstable. C. although pns can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time. D. although aps can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time, particularly assessment. 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 that apply.) A. the roommate ambulates 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 medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of his breakfast this morning. A. the ap does not need to know the status of the client's roommate to complete this assignment. B. CORRECT: to complete this assignment safely, the ap should make sure the client wears stockings and slippers. C. CORRECT: to complete this assignment safely, the ap should make sure the client uses a front‑wheeled walker D. CORRECT: to complete this assignment safely, the ap should know that the client should be feeling the effects of the pain medication. E. the ap does not need to know the client's allergy status to complete this assignment. F. The ap does not need to know the client's food intake to complete this assignment An rn is making assignments for a practical nurse (pn) at the beginning of the shift. Which of the following assignments should the pn question? A. assisting a client who is 24‑hr postoperative to use an incentive spirometer B. Collecting a clean‑catch urine specimen from a client who has a wound infection C. providing nasopharyngeal suctioning for a client who has pneumonia D. teaching a client who has asthma to use a metered‑dose inhaler A. assisting a client to use an incentive spirometer is within the scope of practice of the pn. B. Collecting a clean‑catch urine specimen is within the scope of practice of the pn. C. providing nasopharyngeal suctioning is within the scope of practice of the pn. D. CORRECT: the rn is responsible for primary teaching. the pn may only reinforce teaching A nurse is preparing an in‑service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply.) A. right client B. right supervision and evaluation C. right direction and communication D. right time E. right circumstances A. the right client is one of the rights of medication administration, not of delegation. B. CORRECT: the right supervision and evaluation is one of the five rights of delegation. they also include the right task and the right person. C. CORRECT: right direction and communication is one of the five rights of delegation. they also include the right task and the right person. D. although the delegatee needs to know whether there is a time frame or a specific time to perform the task, the right time is not one of the five rights of delegation. it is one of the rights of medication administration. E. CORRECT: the right circumstances is one of the five rights of delegation. they also include the right task and the right person A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply. A. Use a lift sheet when moving and positioning the patient in bed B. Use an electric razor when shaving the patient each day C. Use a soft-bristled toothbrush or tooth sponge for oral care D. Use a rectal thermometer to obtain a more accurate body temperature E. Be sure the patient's footwear has a firm sole when the patient ambulates Answers: A, B, C, and E. While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate to the care of a patient receiving anticoagulants. A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)? A. Assisting the patient to sit up on the side of the bed B. Instructing the patient to cough effectively C. Teaching the patient to use incentive spirometry D. Auscultation of breath sounds every 4 hours Answer: A. Assisting the patient to sit up on the side of the bed Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse. A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)? A. Discuss weight-loss strategies such as diet and exercise with the patient B. Teach the patient how to set up the BiPAP machine before sleeping C. Remind the patient to sleep on his side instead of his back. D. Administer modafinil (Provigil) to promote daytime wakefulness Answer: C. Remind the patient to sleep on his side instead of his back. The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN. After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately? A. Heart rate of 98 beats/min B. Respiratory rate of 24 breaths/min C. Blood pressure of 168/90 mm Hg D. Tympanic temperature of 101.4 F (38.6 C) Answer: D. Tympanic temperature of 101.4 F (38.6 C) Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system. An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI) C. Complete in-depth admission assessment D. Initiate the nursing care plan E. Evaluate the patient's technique for using MDI's Answers: A and B. The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient's abilities require additional education and skills. These actions are within the scope of practice of the professional RN. [Show Less]
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RN/LPN/UAP Scope of Practice questions and answers 2023
Ambulating the client RN, LPN, and UAP/CNA (if stable client). Measure client for crutches, walker, and cane. RN and LPN. Ambulate client u... [Show More] sing crutches, walker, and cane. RN and LPN. Apply heat lamps, heating pads, warm moist soaks, and cold applications. RN and LPN. Applying restraints of all types. RN Assist with performing ADLs. RN, LPN, and UAP/CNA. CVP monitoring: Check and interpret central venous pressure. RN Assist MD with inserting central catheter. RN and LPN (with certification). Collecting specimens (sputum, wound, urine, and stool) RN, LPN, and UAP/CNA (urine). Interpret ECG/EKG monitor; knowing life-threatening arrythmias and management of each. RN and LPN. Start, Manage, and Discontinue IV infusions. RN Mantain, Regulate, and Discontinue IV infusions according to written protocol. LPN Inserting PICC line with certification. RN Hang/Monitor blood transfusions. RN Take VS on client receiving blood transfusions. RN (primary nurse) and LPN. Insert vaginal/rectal suppositories. RN and LPN. Administer IV meds, IV push, and hang IV piggybacks. RN and LPN (certified to give IV meds and hanging piggybacks, but not IV Push). Administer oral meds, topical meds, intramuscular, intradermal, and SubQ injections. RN and LPN. Insert NG tube for Levin suction or gavage feedings; give meds through NG and PEG tubes; Discontinue NG tubes. RN and LPN. Responsible for teaching prior to discharge. RN Reinforce teaching (after RN does initial teaching). LPN Suction/provide ventilator support. (Nurse is expected to know how to manage a client on a ventilator). RN and LPN. Clean trach/Provide O2. RN and LPN. Set up and maintain skin traction. RN and LPN. Insert foley and french catheters; irrigate foley with MD order; and discontinue foley/french catheter. RN and LPN. Taking vital signs (Temp, HR, BP, RR) RN, LPN, UAP/CNA (standard routine care on stable client). Taking vital signs and evaluating them. RN and LPN. Wound care: perform decubitus care; cast care; and sterile dressing changes. RN and LPN. Performing fingerstick glucose checks. RN and LPN. In the NCLEX world, nursing assistants CANNOT do this. [Show Less]
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ATI Fundamentals Chapter 2 questions and answers 2023
interprofessional overlaps Each discipline represented on an _________________ team uses a set of skills within the scope of practice for the specific ... [Show More] profession. In some instances, the scope of practicer one discipline ___________ with the scope of practice or set of skills for another profession The __________ is most often the manager of care and must understand the roles and responsibilities of other health care team members to collaborate and make appropriate referrals. Spiritual Support Staff *Interprofessional Personnel (Non-Nursing) __________ -__________ _________: Provides spiritual care (pastors, rabbis, priests) Ex of when to refer: A client requests communion, or the family asks for prayer prior to the client undergoing procedure Registered Dietitian ___________ ___________: Assesses, plans for, and educates regarding nutrition needs. Designs special diets, and supervises meal preparation. Ex of when to refer: A client has a low albumin level and recently had an unexplained weight loss Laboratory Technician ____________ ____________: Obtains specimens of body fluids and performs diagnostic tests. Ex of when to refer: A provider needs see a client's complete blood count (CBC) results immediately. Occupational Therapist _____________ _____________: Assesses and plans for clients to regain activities of daily living (ADL) skills, especially motor skills of the upper extremities Ex of when to refer: A client has difficulties using an eating utensil with her dominant hand following a stroke Pharmacist _______________: Provides and monitors medication. Supervises pharmacy technicians in states that allow this practice. Ex of when to refer: A client is concerned about a new medications interactions with any of his other medications Physical Therapist _______________ ____________: Assesses and plans for clients to increase musculoskeletal function, especially of the lower extremities, to maintain mobility. Ex of when to refer: Following a hip arthroplasty, a client requires assistance learning to ambulate and regain strength Provider _____________: Assess, diagnoses and treats disease and injury. Include medical doctors, doctors of osteopathy, advanced practice nurses, and physician assistants. Ex of when to refer: A client has a temperature of 102.2, is achy and shaking and reports feeling cold Radiologic Technologist _______________ _______________: Positions clients and performs x-rays and other imaging procedures to review for diagnosis of disorders of various body parts. Ex of when to refer: A client reports severe pain in his hop after a fall, and the provider prescribes an x-ray of the clients hip Radiologic Therapist ___________ ______________: Evaluates respiratory status and provides respiratory treatments including oxygen therapy, chest physiotherapy, inhalation therapy, and mechanical ventilation. Ex of when to refer: A client who has respiratory disease is short of breath and requests a nebulizer treatments Social Worker ___________ ___________: Works with clients and families by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and discharge Ex of when to refer: A client who has terminal cancer wishes to go home but is no longer able to perform many ADLs. The clients partner needs medical equipment in the home to care for the client Speech-Language Pathologist __________-_________ ____________: Evaluates and makes recommendations regarding the impact of disorders or injuries on speech, language, and swallowing. Teaches techniques and exercises to improve function. Ex of when to refer: A client is having difficulty swallowing a regular diet after trauma to the head and neck RN The ______ is the lead team member, soliciting input from all nursing team members, setting priorities, sharing information with other disciplines, and coordinating client care -Must meet the state board of nursing's requirements for licensure -Requires completion of a diploma program, an associate degree, or a baccalaureate degree in nursing prior to taking the licensure exam (licensed) Educational Preparation for a Registered Nurse: -Function legally under state nurse practice acts -Perform assessments, establish nursing diagnoses, goals, and interventions, and conduct ongoing client evaluations -Participate in developing inter professional plans for client care -Share appropriate information among team members, initiate referrals for client assistance, including heath education and identify community resources Roles and Responsibilities for a Registered Nurse: -Must meet the state board of nursing requirements -Requires vocational or community college education prior to taking the licensure exam Educational Preparation for a Practical Nurse: -Work under the supervision of the RN -Collaborate within the Nursing process, coordinate the plan of care, consult with other team members, and recognize the need for referrals to assist with actual or potential problems -Participate in the delivery of nursing care, using the nursing process as a framework Roles and Responsibilities for a Practical Nurse: Assistive Personnel ____________ _____________ includes certified nursing assistants (CNAs) and certified medical assistants (CMAs) and non-nursing personnel such as dialysis technicians, monitor technicians and phlebotomists -Must meet the states formal or informal training requirements -Requirements by most states for training and examination to attain CNA status Educational Preparation for Assistive Personnel: -Work under the direct supervision of an RN or PN -Position description in the employing facility outlines specific tasks -Tasks can include feeding clients, preparing nutritional supplements, lifting, basic care (grooming, bathing, transferring, toiling, positioning) measuring and recording vital signs, and ambulating clients Roles and Responsibilities for Assistive Personnel: Advanced Practice Nurse (APN) Expanded Nursing Roles _____________ ______________ ____________: Has a great deal of autonomy. APNs have a minimum of a masters degree in nursing (or related field), advanced education in pharmacology and physical assessment, and certification in a specialized area of practice Included in this role are the following: Clinical Nurse Specialist (CNS) ____________ ____________ ______________: Typically specializes in a practice setting or a clinical field Nurse Practitioner ___________ ______________: Collaborated with one or more providers to deliver nonemergency primary health care in a variety of settings Certified Registered Nurse Anesthetist ____________ _____________ ____________ ______________ : Administers anesthesia and provides care during procedures under the supervision of an anesthesiologist Certified Nurse-Midwife (CNM) ____________ __________-_________: Collaborates with one or more providers to deliver care to maternal-newborn clients and their families Nurse Educator _____________ _______________: Teaches in schools of nursing, staff developments in health care facilities, or client education departments [Show Less]
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ATI 2: Scope and Standards of Practice questions answered 100% correct
A newly licensed nurse is reviewing information about the National Council of state board of nursing transition to practice program. Which of the following... [Show More] factors should the nurse expect? Ttp programs increase job retention A graduate nurse is offered a position in the emergency department upon the granting of initial licensure. Which of the following information should the graduate nurse identify as a requirement during the initial licensure process? Verification of graduation, criminal background check in certain states, passing score on the NCLEX examination, self disclosure of any substance use in the past five years A nurse is delivering client care in partnership with multidisciplinary members of the healthcare team. This is an example of which of the following QSEN competencies? Teamwork and collaboration A newly licensed nurse is reviewing the standards of care when performing client care. Which of the following describes a standard of care? The level of care nurse provides that is the same for all nurses who have comparable education, competency, and experience A nurse receives a license renewal notification from the board of nursing. The nurse should identify that a license renewal requires the disclosure of which of the following? Substance use within the past five years A nurse hold a single state nursing license and is preparing to move to another state. For the nurse to apply for reciprocity see which of the following action should the nurse take? Present a current invalid nursing license, submit an application, pay the fees for a new license A nurse resides in a state that recently enacted the nurse licensure compact. Which of the following information should the nurse identify as a part of the NLC? The NLC allows a nurse to practice across state lines with one license A nurse is responsible for their actions with whom they interact professionally, including clients, colleagues, and society as a whole. Which of the following components of the practice of nursing address is expected behavior? Standards of professional performance A nurse is providing client care using the nursing process. The nurse should identify that which of the following standards or guidelines includes this criterion? Standards of practice A nurse is teaching a group of nurses and asks which of the NL and integrating competencies is defined as having respect for diversity, holistic care, client centered approach, and client advocacy. Which of the following competencies does this describe? Human flourishing A nurse is reviewing the scope of nursing practice. Which of the following is the purpose of the nursing scope of practice? Specifies the actions a nurse can perform A newly licensed nurse is reviewing electronic information about the NCLEX exam from the national Council of state board of nursing website. Which of the following information should the nurse identify as passing criteria for the NCLEX computerized adaptive test? The computer will stop giving items using the 95% confidence interval rule [Show Less]
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ATI Scope and Standards of Practice questions answered 100% correct
Scope of Practice Defines those duties that a nurse is considered competent to carry out and authorized to perform as defined by state law. In other words... [Show More] , the scope of practice stipulates those activities nurses can and cannot perform legally. Standards of Professional Performance Define competent behavior of all registered nurses and licensed practical nurses where care is provided in an ethical manner with respect for cultural diversity Nurse Practice Act Current laws and regualtins governing nursing practice in every state and territory of the United States NCLEX A national computer-adapted standardized, graded, pass/fail test used to determine if a graduate nurse is ready to become licensed as an entry-level nurse Nurse Licensure Compact An agreement that allows nurses to practice in other NLC states without having to obtain additional licenses Which of the NLN integrating competencies is defined as having respect for diversity, holistic care, client centered approach, and client advocacy. Human Flourishing Defined as the nurse providing client care that demonstartes respect for diversity approaches clients in a holistic and client-centered manner, and uses advocacy to enhance a clients' health Which of the following information should the nurse identify as a passing criteris for the NCLEX computerized test (CAT) The computer will stop giving items using the 95% confidence interval rule. A nurse resides in a state that recently enacted the Nursing Licensure Compact (NLC). Which of the following information should the nurse identify as part of the NLC? The NLC allows a nurse to practice across state lines with one license A nurse receives a license renewal notification from the board of nursing. The nurse should identify that a license renewal requires the disclosure of which of the following? When renewing a nursing license, the applicant is required to disclose any history of criminal record, substance use within the past 5 years, and any action taken against a professional license, registration, or certification A nurse is providing client care using the nursing process. The nurse should identify that which of the following standards or guideline includes this criterion Standards of practice Standards of practice are explanatory statements that describe a compentent level of care for all nurses using the critical thinking model known as the nursing process. Nursing has general standards of practive to which every nurse is held accountable. A nurse is reviewing the scope of nursing practice. Which of the following is the purpose of the nursing scope of practice? Specifies the actions a nurse can perform. What information should the graduate nurse identify as a requirement during the initial licensure process? SATA 1. Verification of graduation 2. Criminal background check in certain states 3. Passing score on the NCLEX examination 4. Self-disclosure of any substance use in the past 5 years Transition to practice programs (TTP). Which of the following factors should the nurse expect? TPP programs increase job retention Which of the following statements should the nurse use to define licensure? Licensure protects the health and welfare of the public Which of the following describes a standard of care? A standard of care is defined as a level of care a nurse provides that is the same for all nurses who have comparable education, competency, and experiences. Multidisciplinary members of the health care team. This is an example of which of the following QSEN competencies? Teamwork and collaboration A nurse is educating a group of nurses about the Nurse Practice Act (NPA). Which of the following stateemnt should the nurse include? SATA 1. The NPA contains current laws and regulations for nursing practice 2. The NPA contains standards and scop of practice 3. The Nurse is respnsible to know the current roles and responsibilities as defined by the NPA [Show Less]
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