ATI Fundamentals: Documentation, Legal & Ethical Nursing Practice
2026 |Questions |Answers |Rationales
1. A nurse is documenting in a client’s medical record. Which of the following
entries should the nurse identify as an objective finding?
A. Client seems depressed today.
B. Client states, ‘I feel very nauseated.’
C. Client appears to be in a lot of pain.
D. Client’s skin is warm and dry to the touch.
Answer: D
Rationale: Objective data are observable and measurable facts. Skin temperature and
moisture can be felt and measured. Depression, nausea, and pain levels are subjective or
interpretations.
2. A nurse discovers that a client was administered the wrong medication.
Which of the following actions should the nurse take first?
A. Complete an incident report.
B. Notify the provider.
C. Assess the client’s vital signs.
D. Inform the nurse manager.
Answer: C
Rationale: The first action in the nursing process is assessment. The nurse must check the
client’s condition to ensure safety before proceeding with reporting.
,3. Which ethical principle is being applied when a nurse supports a client’s
decision to refuse chemotherapy?
A. Beneficence
B. Autonomy
C. Justice
D. Fidelity
Answer: B
Rationale: Autonomy is the right of the patient to make their own decisions about their
medical care, even if the nurse or provider disagrees.
4. A nurse is caring for a client who is scheduled for surgery. The client says, ‘I
am not sure I want this procedure anymore.’ Which action should the nurse
take?
A. Tell the client the surgery is necessary for recovery.
B. Ask the client’s family to convince them.
C. Ask the client to sign the consent form anyway.
D. Inform the surgeon that the client has questions about the procedure.
Answer: D
Rationale: It is the provider’s responsibility to provide information and clarify risks. The
nurse’s role is to advocate and notify the provider if the client is hesitant.
5. A nurse is unsure how to perform a specific dressing change ordered for a
client. Which resource should the nurse consult first?
A. The charge nurse
B. The facility’s policy and procedure manual
C. A senior nurse on the unit
D. The client’s primary care provider
Answer: B
, Rationale: The facility’s policy and procedure manual provides the official, evidence-based
standard of care for that specific institution.
6. A nurse discusses a client’s laboratory results with a colleague in the hospital
elevator. Which legal or ethical violation has occurred?
A. Libel
B. Defamation
C. Slander
D. Breach of confidentiality
Answer: D
Rationale: Discussing patient information in a public area where others can overhear is a
violation of HIPAA and the client’s right to confidentiality.
7. A client has a Living Will that specifies no intubation. The family requests the
nurse to intubate. What is the nurse’s priority action?
A. Honor the client’s Living Will.
B. Wait for the ethics committee to meet.
C. Follow the family’s wishes.
D. Call the provider for a new order.
Answer: A
Rationale: A Living Will is a legal document that expresses the client’s wishes. It takes
precedence over the family’s requests if the client is unable to speak for themselves.
8. A nurse documents: ‘The client is being difficult and refusing to cooperate.’
This is an example of which documentation error?
A. Objective reporting
B. Inclusive charting
C. Accurate description
D. Subjective labeling
Answer: D
2026 |Questions |Answers |Rationales
1. A nurse is documenting in a client’s medical record. Which of the following
entries should the nurse identify as an objective finding?
A. Client seems depressed today.
B. Client states, ‘I feel very nauseated.’
C. Client appears to be in a lot of pain.
D. Client’s skin is warm and dry to the touch.
Answer: D
Rationale: Objective data are observable and measurable facts. Skin temperature and
moisture can be felt and measured. Depression, nausea, and pain levels are subjective or
interpretations.
2. A nurse discovers that a client was administered the wrong medication.
Which of the following actions should the nurse take first?
A. Complete an incident report.
B. Notify the provider.
C. Assess the client’s vital signs.
D. Inform the nurse manager.
Answer: C
Rationale: The first action in the nursing process is assessment. The nurse must check the
client’s condition to ensure safety before proceeding with reporting.
,3. Which ethical principle is being applied when a nurse supports a client’s
decision to refuse chemotherapy?
A. Beneficence
B. Autonomy
C. Justice
D. Fidelity
Answer: B
Rationale: Autonomy is the right of the patient to make their own decisions about their
medical care, even if the nurse or provider disagrees.
4. A nurse is caring for a client who is scheduled for surgery. The client says, ‘I
am not sure I want this procedure anymore.’ Which action should the nurse
take?
A. Tell the client the surgery is necessary for recovery.
B. Ask the client’s family to convince them.
C. Ask the client to sign the consent form anyway.
D. Inform the surgeon that the client has questions about the procedure.
Answer: D
Rationale: It is the provider’s responsibility to provide information and clarify risks. The
nurse’s role is to advocate and notify the provider if the client is hesitant.
5. A nurse is unsure how to perform a specific dressing change ordered for a
client. Which resource should the nurse consult first?
A. The charge nurse
B. The facility’s policy and procedure manual
C. A senior nurse on the unit
D. The client’s primary care provider
Answer: B
, Rationale: The facility’s policy and procedure manual provides the official, evidence-based
standard of care for that specific institution.
6. A nurse discusses a client’s laboratory results with a colleague in the hospital
elevator. Which legal or ethical violation has occurred?
A. Libel
B. Defamation
C. Slander
D. Breach of confidentiality
Answer: D
Rationale: Discussing patient information in a public area where others can overhear is a
violation of HIPAA and the client’s right to confidentiality.
7. A client has a Living Will that specifies no intubation. The family requests the
nurse to intubate. What is the nurse’s priority action?
A. Honor the client’s Living Will.
B. Wait for the ethics committee to meet.
C. Follow the family’s wishes.
D. Call the provider for a new order.
Answer: A
Rationale: A Living Will is a legal document that expresses the client’s wishes. It takes
precedence over the family’s requests if the client is unable to speak for themselves.
8. A nurse documents: ‘The client is being difficult and refusing to cooperate.’
This is an example of which documentation error?
A. Objective reporting
B. Inclusive charting
C. Accurate description
D. Subjective labeling
Answer: D
