NUR220 Module 1 Exam ATI QUESTIONS AND ANSWERS CORRECTLY ANSWERED| GRADED A+

CH4 LEGAL RESPONSIBILITIES 1. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? (a) Assault (b) Battery (c) False imprisonment (d) Invasion of privacy - correct answers (a) CORRECT: By threatening the client, the AP is committing assault. The AP's threats could make the client become fearful and apprehensive. (b) INCORRECT: Battery is actual physical contact without the client's consent. Because the AP has only verbally threatened the client, battery has not occurred. (c) INCORRECT: Unless the AP restrains the client, there is no false imprisonment involved. (d) INCORRECT: Invasion of privacy involves disclosing information about a client to an unauthorized individual. 2. A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that his is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? (a) Assault (b) False imprisonment (c) Negligence (d) Breach of confidentiality - correct answers (b) CORRECT: Administering a medication as a chemical restraint to keep the client from leaving the facility against medical advice is false imprisonment, because the client neither requested nor consented to receiving the sedative. (a) INCORRECT: Assault is an action that threatens harmful contact without the client's consent. The nurse has made no threats in this situation. (c) INCORRECT: Negligence is a breach of duty that results in harm to the client. It is unlikely that the medication the nurse administered without his consent actually harmed the client. (d) INCORRECT: The nurse has not disclosed any protected health information, so there is no breach of confidentiality involved in this situation. 3. A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of 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 wont go ahead with the surgery unless I prepare term-3these 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." - correct answers C. CORRECT: The client has the right to decide and specify which medical procedures he wants when a life‑threatening situation arises. (a) INCORRECT: The client can designate any competent adult to be his health care proxy. It does not have to be his spouse. (b) INCORRECT: The hospital staff must ask the client whether he has prepared advance directives and provide written information about them if he has not. The nurse should document whether the client has signed the advance directives. The hospital staff cannot refuse care based on the lack of advance directives. (d) INCORRECT: The client does not need his provider's approval to submit his advance directives. However, he should give his primary care provider a copy of the document for his records. 4. A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) (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. - correct answers (a) CORRECT: It is the nurse's responsibility to verify that the surgeon obtained the client's consent and that the client understands the information the surgeon gave them. (b) CORRECT: It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that they are consenting voluntarily and appear to be competent to do so. The nurse also should verify that the client understands the information the surgeon has provided. (c) INCORRECT: It is the surgeon's responsibility to explain the risks and benefits of the procedure. (d) INCORRECT: It is the surgeon's responsibility to describe the consequences of choosing not to have the surgery. (e) INCORRECT: It is the surgeon's responsibility to tell the client about any available alternatives to having the surgery. 5. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? (a) Alert the American Nurses Association. (b) Fill out an incident report. (c) Report the observations to the nurse manager on the unit. (d) Leave the nurse alone to sleep. - correct answers (c) CORRECT: Any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager. (a) INCORRECT: Do not alert the American Nurses Association. The state's board of nursing regulates disciplinary action and can revoke a nurse's license for substance use. (b) INCORRECT: Do not fill out an incident report. Incident reports are filed to document an accident or unusual occurrence. (d) INCORRECT: Do not leave the nurse alone to sleep. Although the nurse is not responsible for solving the problem, she does have a duty to take action because she has observed the problem. CH5 INFORMED TECHNOLOGY 1. A nurse is preparing information for a change‑of‑shift report. Which of the following information should the nurse include in the report? (a) Input and output for the shift (b) Blood pressure from the previous day (c) Bone scan scheduled for today (d) Medication routine from the medication administration record - correct answers (c) CORRECT: The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit. (a) INCORRECT: Unless there is a significant change in intake and output, the oncoming nurse can read that information in the chart. (b) INCORRECT: Unless there is a significant change in blood pressure measurements since the previous day, the oncoming nurse can read that information in the chart. (d) INCORRECT: Unless there is a significant change in the medication routine, the oncoming nurse can read that information in the chart. 2. A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) (a) A single electronic records password is provided for nurses on the same unit. (b) Family members should provide a code prior to receiving client health information. (c) Communication of client information can occur at the nurses' station. (d) A client can request a copy of their medical record. (e) A nurse can photocopy a client's medical record for transfer to another facility. - correct answers B. CORRECT: The HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. Many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code (c) CORRECT: The HIPAA Privacy Rule states that communication about a client should only take place in a private setting where unauthorized individuals cannot overhear it. A unit nurses' station is considered a private and secure location. (d) CORRECT: The HIPAA Privacy Rule states that clients have a right to read and obtain a copy of their medical record. (e) CORRECT: The HIPAA Privacy Rule states that nurses can only photocopy a client's medical record if it is to be used for transfer to another facility or provider. (a) INCORRECT: The HIPAA Privacy Rule requires the protection of clients' electronic records. The rule states that electronic records must be password-protected and each staff person should use an individual password to access information. . 3. A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) (a) Cover errors with correction fluid, and write in the correct information. (b) Put the date and 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 shift to document. - correct answers (b) CORRECT: The day and time confirm the recording of the correct sequence of events. (c) CORRECT: Documentation must be factual, descriptive, and objective, without opinions or criticism. (a) INCORRECT: Correction fluid implies that the nurse might have tried to hide the previous documentation or deface the medical record. (d) INCORRECT: Too many abbreviations can make the entry difficult to understand. Nurses should minimize use of abbreviations, and use only those the facility approves. (e) INCORRECT: Documentation should be current. Waiting until the end of the shift can result in data omission. 4. A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply). (a) Medication error (b) Needlesticks (c) Conflict with provider and nursing staff (d) Omission of prescription (e) Missed specimen collection of a prescribed laboratory test - correct answers (a) CORRECT: Complete an incident report regarding a medication error. (b) CORRECT: Complete an incident report regarding a needlestick. (d) CORRECT: Complete an incident report following an omission of a prescription (c) INCORRECT: Report a conflict with a provider and nursing staff to the charge nurse or nurse manager. (e) INCORRECT: Report missed specimen collection of a prescribed laboratory test. 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 that apply.) (a) Repeat the details of the prescription back to the provider. (b) Have another nurse listen to the telephone prescription. (c) Obtain the provider's signature on the prescription within 24 hr. (d) Decline the verbal prescription because it is not an emergency situation. (e) Tell the charge nurse that the provider has prescribed morphine by telephone. - correct answers (a) CORRECT: The nurse should repeat the medication's name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation. (b) CORRECT: Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication. (c) CORRECT: The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr). (d) INCORRECT: Unrelieved pain can become an emergency situation without the appropriate pain management interventions. (e) INCORRECT: There is no need to inform the charge nurse every time a nurse receives a medication prescription, whether by telephone, verbally, or in the medical record. CH9 ADMISSIONS, TRANSFERS, AND DISCHARGE 1. A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? (a) Orient the client to their room. (b) Conduct a client care conference. (c) Review medical prescriptions. (d) Develop a plan of care. - correct answers (a) CORRECT: The greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient the client to the room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at the bedside. (b) INCORRECT: Conduct a client care conference. However, another action is the priority. (c) INCORRECT: Review prescriptions in the medical record. However, another action is the priority. (d) INCORRECT: Develop a plan of care. However, another action is the priority. 2. A nurse is admitting a client who has acute cholecystitis to a medical‑surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply.) (a) Explain the roles of other care delivery staff. (b) Begin discharge planning. (c) Inform the client that advance directives are required for hospital admission. (d) Document the client's wishes about organ donation. (e) Introduce the client to their roommate. - correct answers (a) CORRECT: The client's hospitalization is likely to be more positive if the client understands who can perform which care activities. (b) CORRECT: Unless the client is entering a long‑term care facility, discharge planning should begin on admission. (d) CORRECT: Upon hospital admission, required request laws direct providers to ask clients older than 18 years if they are organ or tissue donors. (e) CORRECT: Any action that can reduce the stress of hospitalization is therapeutic. Introductions to other clients and staff can encourage communication and psychological comfort. (c) INCORRECT: The Patient Self‑Determination Act does not require that clients have advance directives prior to hospital admission. The act requires asking clients if they have advance directives. 3. A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply.) (a) Ensure that the client has possession of their valuables. (b) Confirm that the rehabilitation center has a room available at the time of transfer. (c) Assess how the client tolerates the transfer. (d) Give a verbal transfer report via telephone. (e) Complete a transfer form for the receiving facility. - correct answers (a) CORRECT: Account for all of the client's valuables at the time of transfer. (b) CORRECT: On the day of the transfer, confirm that the receiving facility is expecting the client and that the room is available. (d) CORRECT: Provide the nurse at the receiving facility with a verbal transfer report in person or via telephone. (e) CORRECT: Complete any documentation for the transfer, including a transfer form and the client's medical records. (c) INCORRECT: It is the responsibility of the nurse at the receiving facility to assess the client upon arrival to determine how they tolerated the transfer. 4. A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply.) (a) Advance directives status (b) Follow‑up care (c) Instructions for diet and medications (d) Most recent vital sign data (e) Contact information for the home health care agency - correct answers (b) CORRECT: It is essential to include the names and contact information of providers and community resources the client will need after they return home. (c) CORRECT: The client will need written information detailing home medication and dietary therapy. A client who has had knee arthroscopy typically requires analgesics, possibly anticoagulants, and dietary instructions for avoiding postoperative complications (constipation). (e) CORRECT: It is essential to include the names and contact information of providers and community resources the client will need after returning home. For example, a client who had a knee arthroplasty might require physical therapy at home until able to travel to a physical therapy department or facility. (a) INCORRECT: Advance directives status is important in transfer documentation, when other care providers will take over a client's care. They are not an essential component of a discharge summary for a client who is returning to their home. (d) INCORRECT: Vital sign measurements are important in transfer documentation, when other care providers will take over a client's care. They are not an essential component of a discharge summary for a client who is returning home. 5. As part of the admission process, a nurse at a long‑term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? (a) Body mass index (b) Usual times for meals and snacks (c) Favorite foods (d) Any difficulty swallowing - correct answers (d) CORRECT: The greatest risk to this client related to a nutrition‑related evaluation is from difficulty swallowing, or dysphagia. It puts the client at risk for aspiration, which can be life‑threatening. (a) INCORRECT: It is important to calculate body mass index to determine the client's weight status and related risks. However, there is a higher priority. (b) INCORRECT: It is important to know and try to follow the meal schedule the client follows at home. However, there is a higher priority. (c) INCORRECT: It is important to know which foods are the client's favorites in case it becomes difficult to get the client to consume adequate nutrients. However, there is a higher priority. CH10 MEDICAL AND SURGICAL ASEPSIS 1. When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? (a) Keep the sterile field at least 6 ft away from the client's bedside. (b) Instruct the client to refrain from coughing and sneezing during the dressing change. (c) Place a mask on the client to limit the spread of micro‑organisms into the surgical wound. (d) Keep a box of facial tissues nearby for the client to use during the dressing change. - correct answers (c) CORRECT: Placing a mask on the client prevents contamination of the surgical wound during the dressing change. (a) INCORRECT: It would be difficult for to maintain a sterile field away from the bedside. But more important, this might not have any effect on the transmission of some micro‑organisms. (b) INCORRECT: The client might be unable to refrain from coughing and sneezing during the dressing change. (d) INCORRECT: Keeping tissues close by for the client to use still allows contamination of the surgical wound. 2. A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? (a) The flap closest to the body (b) The right side flap (c) The left side flap (d) The flap farthest from the body - correct answers (d) CORRECT: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one farthest from her body) away from the body first, there is a risk of touching part of the inner surface of the wrap and thus contaminating it. (a) INCORRECT: The flap closest to the body is the innermost flap and the last one to unfold. (b) INCORRECT: Unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap to unfold first. (c) INCORRECT: Unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap to unfold first. 3. A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) (a) A bottle containing a sterile solution (b) The edge of the sterile drape at the base of the field (c) The inner wrapping of an item on the sterile field (d) An irrigation syringe on the sterile field (e) One gloved hand with the other gloved hand - correct answers (c) CORRECT: The inner wrappings of any objects dropped onto the sterile field are sterile. Touch them with sterile gloves. (d) CORRECT: Any objects dropped onto the sterile field during the setup are sterile. Touch the syringe with sterile gloves. (e) CORRECT: One sterile gloved hand may touch the other sterile gloved hand because both are sterile. (a) INCORRECT: A bottle of sterile solution is sterile on the inside and non-sterile on the outside. Prepare the sterile container of solution on the field before putting on sterile gloves. (b) INCORRECT: The 1‑inch border at the outer edge of the sterile field is not sterile. Do not touch it with sterile gloves. 4. . A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) (a) Apply 3 to 5 mL of liquid soap to dry hands. (b) Wash the hands with soap and water for at least 15 seconds. (c) Rinse the hands with hot water. (d) Use a clean paper towel to turn off hand faucets. (e) Allow the hands to air dry after washing. - correct answers (b) CORRECT: This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes. (d) CORRECT: If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands. (a) INCORRECT: The APs should apply alcohol rubs to dry hands and wet the hands first before applying soap for handwashing. (c) INCORRECT: The APs should use warm water to minimize the removal of protective skin oils. (e) INCORRECT: The APs should dry their hands with a clean paper towel. This helps prevent chapped skin. 5. A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) (a) The provider drops a sterile instrument onto the near side of the sterile field. (b) The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. (c) The procedure is delayed 1 hr because the provider receives an emergency call. (d) The nurse turns to speak to someone who enters through the door behind the nurse. (e) The client's hand brushes against the outer edge of the sterile field. - correct answers (b) CORRECT: Fluid permeation of the sterile drape or barrier contaminates the field. (c) CORRECT: Prolonged exposure to air contaminates a sterile field. (d) CORRECT: Turning away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field. (a) INCORRECT: As long as the provider has not reached over the sterile field (by placing the instrument on a near portion of the field), the field remains sterile. (e) INCORRECT: The 1‑inch border at the outer edge of the sterile field is not sterile. Unless the client reached farther into the field, the field remains sterile. CH11 INFECTION CONTROL 1. A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) (a) Planning and evaluating control and prevention strategies (b) Determining public health priorities (c) Ensuring proper medical treatment (d) Identifying endemic disease (e) Monitoring for common‑source outbreaks - correct answers (a) CORRECT: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies. (b) CORRECT: Reporting of communicable and infectious diseases assists with determining public health policies. (c) CORRECT: Reporting of communicable and infectious diseases assists with ensuring proper medical treatment is available. (e) CORRECT: Reporting of communicable and infectious diseases assists with monitoring for common‑source outbreaks. (d) INCORRECT: Endemic disease is already prevalent within a population, so reporting is not necessary. 2. A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? (a) Allergic reaction (b) Ringworm (c) Systemic lupus erythematosus (d) Tuberculosis - correct answers (d) CORRECT: A cough for 3 weeks and beginning to cough up blood are manifestations of tuberculosis (a) INCORRECT: A pink body rash is a manifestation of an allergic reaction. (b) INCORRECT: Red circles with white centers is a manifestation of ringworm. (c) INCORRECT: A red edematous rash bilaterally on the cheeks is a manifestation of systemic lupus erythematosus. 3. A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? (a) Prodromal (b) Incubation (c) Convalescence (d) Illness - correct answers (d) CORRECT: The illness stage is when the client experiences manifestations specific to the infection. (a) INCORRECT: The prodromal stage consists of nonspecific manifestations of the infection. (b) INCORRECT: The incubation period consists of the time when the pathogen first enters the body prior to the appearance of any manifestations of infection. (c) INCORRECT: During convalescence, manifestations of the infection fade. 4. A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply.) (a) Fever (b) Malaise (c) Edema (d) Pain or tenderness (e) Increase in pulse and respiratory rate - correct answers (a) CORRECT: A fever indicates that the infection is affecting the whole body, and therefore systemic. (b) CORRECT: Malaise indicates that the infection is affecting the whole body. (e) CORRECT: An increase in pulse and respiratory rate indicates that the infection is affecting the whole body. (c) INCORRECT: Edema is a localized manifestation indicating a localized infection. (d) INCORRECT: Pain and tenderness is a localized manifestation indicating a localized infection. 5. A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all that apply.) (a) Place the client in a room that has negative air pressure of at least six exchanges per hour. (b) Wear a mask when providing care within 3 ft of the client. (c) Place a surgical mask on the client if transportation to another department is unavoidable. (d) Use sterile gloves when handling soiled linens. (e) Wear a gown when performing care that might result in contamination from secretions. - correct answers (b) CORRECT: Wear a mask when within 3 ft of the client. (c) CORRECT: Place a surgical mask on the client during transport to another area of the facility.