ATI RN
ATI Fundamentals Proctored Exam Study Guide 3 Questions
Extract:
Question 1 of 5
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 nurse document this in client's chart?
Correct Answer: B
Rationale: The correct answer is B. The nurse should document the client's statement accurately without assuming the fall occurred. This option reflects the client's own account of the situation and acknowledges his ability to self-recover.
Choice A assumes the fall without confirmation.
Choice C is incorrect as it is important to document client reports for continuity of care.
Choice D adds unnecessary information not provided by the client.
Question 2 of 5
Nursing instructor reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in client record? (Select all that apply.)
Correct Answer: B, C
Rationale:
Correct
Answer: B, C
Rationale:
B: Putting date & time on all entries is crucial for legal purposes to establish timeline of events.
C: Documenting objective data without opinions ensures accuracy and prevents subjective bias.
Summary:
A: Covering errors with correction fluid is not recommended as it can be seen as tampering with records.
D: Using excessive abbreviations can lead to misinterpretation and errors in documentation.
E: Waiting until the end of the shift to document can result in missing crucial information or delayed updates.
Question 3 of 5
Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain. Which of the following actions are appropriate? (Select all that apply.)
Correct Answer: A, B, C
Rationale:
Correct
Answer: A, B, C
Rationale:
A: Repeating details back ensures accurate transcription and comprehension.
B: Having another nurse listen ensures a second verification of the prescription.
C: Obtaining the prescriber's signature within 24 hours ensures legal compliance and accountability.
Incorrect
Choices:
D: Declining the prescription could delay pain relief for the client.
E: Informing the charge nurse alone does not ensure proper documentation and accountability.
Question 4 of 5
A nurse on med-surg unit has received change-of-shift report & will care for 4 clients. Which of following client's needs may nurse assign to AP?
Correct Answer: C
Rationale: The correct answer is C. The nurse can assign the task of reapplying a condom catheter for a client with urinary incontinence to an unlicensed assistive personnel (AP) because it is a routine, non-invasive procedure that does not require specialized nursing skills. The AP can be trained to perform this task safely under the nurse's supervision.
A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse.
B: Teaching a client to walk using a quad cane involves assessing the client's safety and gait, which should be done by a licensed nurse.
D: Applying a sterile dressing to a pressure ulcer requires knowledge of wound care principles and infection control, which should be done by a licensed nurse.
Question 5 of 5
Nurse delegating ambulation of client who had knee arthroplasty 5 days ago to an AP. Which of following info should nurse share with the AP? (Select all that apply.)
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. The nurse should share that the client ambulates with slippers over antiembolic stockings (
B) to ensure safety. The nurse should inform that the client uses a front-wheeled walker (
C) to maintain stability during ambulation post-knee arthroplasty. Lastly, sharing that the client had pain medication 30 minutes ago (
D) is crucial for the AP to monitor for potential side effects and adjust care accordingly.
Incorrect choices:
A: The roommate being up independently is irrelevant to the client's ambulation post-knee arthroplasty.
E: The client's allergy to codeine is important medical information but not essential for the AP to know when delegating ambulation.
F: The client's breakfast intake is not directly related to safe ambulation post-knee arthroplasty.