ATI RN Fundamentals
Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? -
ANS Yes.
A nurse on a med-surg 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 - ANS C. Reapplying a condom catheter for a
client who has urinary incontinence
Rationale: The application of a condom catheter is a noninvasive, routine procedure that the
nurse may delegate to the AP
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 - ANS B, C, D
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 shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump - ANS D. Replacing the cartridge and
tubing on a PCA pump
Rationale: The RN is responsible for the PCA pump
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 - ANS B, C, E
,A and D are rights of medication administration
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 - ANS B. RN
A client returning from surgery requires assessment and establishment of a plan of care. RNs
are responsible for this, especially if the client is potentially unstable.
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 - ANS A. Assault
By threatening the client, the AP is committing assault.
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 - ANS B. False imprisonment
The nurse gave the med as a chemical restraint to keep the client from leaving the facility
against medical advice. The client did not consent.
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." - ANS C.
, The client has the right to decide and specify which medical procedures he wants when a
life-threatening situation arrives
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 - ANS A, B
The rest of the choices are the surgeon's responsibility, not the nurse
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 - ANS C.
Any nurse who notices behavior that could possibly jeopardize client care or indicate a
substance abuse problem has a duty to report the situation immediately to the nurse manager
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 shift
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 - ANS C. A bone scan that is scheduled
for today
This is important because the nurse might have to modify the client's care to accommodate
them leaving the unit
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 - ANS B.
By writing what the client states, the info is subjective data
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.
Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? -
ANS Yes.
A nurse on a med-surg 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 - ANS C. Reapplying a condom catheter for a
client who has urinary incontinence
Rationale: The application of a condom catheter is a noninvasive, routine procedure that the
nurse may delegate to the AP
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 - ANS B, C, D
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 shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump - ANS D. Replacing the cartridge and
tubing on a PCA pump
Rationale: The RN is responsible for the PCA pump
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 - ANS B, C, E
,A and D are rights of medication administration
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 - ANS B. RN
A client returning from surgery requires assessment and establishment of a plan of care. RNs
are responsible for this, especially if the client is potentially unstable.
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 - ANS A. Assault
By threatening the client, the AP is committing assault.
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 - ANS B. False imprisonment
The nurse gave the med as a chemical restraint to keep the client from leaving the facility
against medical advice. The client did not consent.
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." - ANS C.
, The client has the right to decide and specify which medical procedures he wants when a
life-threatening situation arrives
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 - ANS A, B
The rest of the choices are the surgeon's responsibility, not the nurse
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 - ANS C.
Any nurse who notices behavior that could possibly jeopardize client care or indicate a
substance abuse problem has a duty to report the situation immediately to the nurse manager
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 shift
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 - ANS C. A bone scan that is scheduled
for today
This is important because the nurse might have to modify the client's care to accommodate
them leaving the unit
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 - ANS B.
By writing what the client states, the info is subjective data
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.
