ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report?
Correct Answer: C
Rationale: The correct answer is C: A bone scan that is scheduled for today. Including this information in the report is crucial as it alerts the oncoming nurse about the upcoming procedure, allowing them to plan and prepare accordingly. This is important for ensuring the client receives timely and appropriate care. The other choices are incorrect because: A (input & output) is important but may not be the priority for a change-of-shift report; B (BP from the previous day) is outdated information and may not be relevant for the current shift; D (med routine) should be documented in the client's chart and can be accessed by the oncoming nurse as needed.
Question 2 of 5
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?
Correct Answer: B
Rationale:
Correct
Answer: B. The client states he fell in the shower & was able to get himself back into his chair.
Rationale: This answer accurately reflects the client's own account of the events without making any assumptions. It documents both the fall and the client's ability to self-recover, which are essential details for the client's care plan.
Summary of Incorrect
Choices:
A: This option only mentions the fall without acknowledging the client's ability to get back up, which is crucial information.
C: It is important to document the client's report even if the nurse did not witness the fall, as it provides valuable insight into the client's condition.
D: This option adds unnecessary information about the client's current state that is not directly related to the fall incident.
Question 3 of 5
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.
Correct Answer: B, C
Rationale:
Correct
Answer: B, C
Rationale:
B: Putting the date and time on all entries is crucial for accurate documentation, ensuring a clear timeline of events for continuity of care and legal purposes.
C: Documenting objective data without opinions maintains professionalism and accuracy, preventing subjective biases from affecting the client's record.
Incorrect
Choices:
A: Covering errors with correction fluid can be seen as tampering with records, potentially leading to legal issues and compromising the integrity of the documentation.
D: Using excessive abbreviations can lead to misinterpretations and errors in communication, jeopardizing patient safety and legal clarity.
E: Waiting until the end of the shift to document can result in information being missed or forgotten, impacting the quality of care and legal accountability.
Question 4 of 5
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.
Correct Answer: A, B, D
Rationale: The correct choices to include in the change-of-shift report are A, B, and D.
Choice A is important to communicate as it highlights that the physical therapist did not ambulate the client due to difficulties with the skin barrier and fistula drainage.
Choice B is crucial as it explains the specific issue with the skin barrier, emphasizing that it stays intact when the client is supine but loosens when standing.
Choice D is essential to include as it informs about the upcoming visit from the wound care nurse.
Choices C and E, although relevant to the client's well-being, are not directly related to the current care plan and should not be included in the report.
Question 5 of 5
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.
Correct Answer: A, B, C
Rationale: The correct choices are A, B, and C. A nurse should repeat the prescription back to the provider to ensure accurate communication and prevent errors. Having another nurse listen to the prescription can provide an additional check for accuracy and clarity. Obtaining the prescriber's signature on the prescription within 24 hours is necessary for documentation and legal purposes.
Choice D should be ruled out as it is not appropriate to decline a valid prescription for pain medication in a timely manner.
Choice E does not address the immediate need to confirm and document the prescription accurately.