ATI RN Fundamentals Proctored Focus
1. Can an RN delegate to the LPN to provide tracheostomy care to a
client with pneumonia?
2. A nurse on a med-surg
... [Show More] unit has received change-of-shift report &
will care for 4 clients. Which of the following client's needs may
the nurse assign to an 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
Rationale: The application of a condom catheter is a noninvasive,
routine procedure that the nurse may delegate to the AP
3. 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
4. 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 shif
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump
5. 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
6. 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
7. 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
8. 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
9. 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."
10. A client is about to undergo an elective surgical procedure. Which
of the following actions are appropriate for the nurse who is providing
preop 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
11. 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
12. 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 shif
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
13. 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
14. 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.
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 shif to document
15. 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 t [Show Less]