ATI KNOWLEDGE AND CLINICAL JUDGEMENT BEGINNING TEST
QUESTIONS WITH COMPLETE SOLUTIONS
A nurse preceptor is orienting a newly licensed nurse. Which of the following
actions by the newly licensed nurse indicates a breach of confidentiality and
requires intervention by the nurse preceptor?
a. Faxing laboratory results to a client's provider
b. Discussing changes in a client's plan of care with his friend who is a nurse on
another unit
c. Describing a client's level of independence to the case manager arranging
home health services
d. Remaining in the room with the client while he reviews his own medical
records - ANSWER-b. Discussing changes in a client's plan of care with his friend
who is a nurse on another unit
In this item, you need knowledge of legal requirements in regard to
confidentiality. Based on this information, you can identify which option
describes an action that indicates a breach of client confidentiality. This is a
negatively worded item that asks you to select the option that indicates an
intervention by the nurse preceptor is warranted. You will learn more about
negatively worded items in Module 4. This item requires critical thinking
because you have to analyze each action in order to interpret the one that
results in a breach of confidentiality. HIPAA is federal legislation that requires
protection of a client's health information and describes the rights and privilege
of clients in regard to privacy and confidentiality. S nurse discussing changes in a
client's plan of care with another nurse on another unit is a breach of
confidentiality. Client information can only be shared with the other health care
,professionals involved in that client's care. The nurse on the other unit should
be directed to the client to request information about changes in the client's
plan of care. This action is not appropriate and requires intervention by the
nurse preceptor.
While collecting data on a client who is immobile, a nurse locates a reddened
area of skin on the left scapula. Which of the following actions should the nurse
take?
a. Reposition of the client every 4 hr
b. Cover the area with a transparent wound barrier
c. Massage areas surrounding the redness
d. Wash the area with hot water every 8 hr - ANSWER-b. Cover the area with a
transparent wound barrier
In this item, you need knowledge of appropriate skin care interventions for
clients who are immobile with indications of a stage I pressure ulcer. This item
requires foundational thinking because you have to recall interventions that are
appropriate for maintaining skin integrity in clients who are immobile. Damage
to tissues caused by continuous pressure is described as a pressure ulcer. The
risk for pressure ulcers can be complicated by factors such as immobility,
inadequate nutrition, bowel and bladder incontinence, decreased mental status,
reduced sensation, increasing age, and excessive body heat. Appropriate care of
pressure ulcers is based on the characteristics and stage of the wound. A wound
that manifests as a reddened area is a stage 1 pressure ulcer. A transparent
wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent
contamination and reduce friction to the area is an appropriate action by the
nurse.
, A nurse is providing discharge education to the parents of a preschooler who is
prescribed acetaminophen (Tylenol) 300 mg every 4 hr as needed. The
acetaminophen liquid suspension that has been prescribed provides 120 mg/5
mL. How many teaspoons should the nurse teach the parents to administer per
dose? - ANSWER-2.5 tsp
In this item, you need knowledge of basic mathematic skills and the formula
used for this type of calculation. Based on your understanding of these
concepts, you can determine the number of teaspoons the nurse should teach
the parents to administer. This item requires critical thinking because you have
to analyze the provided information to determine the dosage, select the
formula, enter data into the formula, and then perform the needed calculations.
STEP 1: What is the dose needed? Dose needed = Desired; 300 mg
STEP 2: What is the dose available? Dose available = Have; 120 mg
STEP 3: Do the units of measurement need to be converted? No (mg=mg).
STEP 4: What is the quantity of the dose available? 5 mL
STEP 5: Set up an equation and solve:
Desired x Quantity / Have = Amount to be given; 300 mg x 5 mL / 120 mg = x mL;
x = 12.5 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 12.5 mL / x;
5x = 12.5; x = 2.5 tsp
A nurse is collecting data on a recently admitted client. Which of the following
techniques should the nurse use to measure tissue perfusion?
a. Determining the client's respiratory rate
b. Measuring the client's chest diameter
c. Obtaining the client's level of oxygen saturation
QUESTIONS WITH COMPLETE SOLUTIONS
A nurse preceptor is orienting a newly licensed nurse. Which of the following
actions by the newly licensed nurse indicates a breach of confidentiality and
requires intervention by the nurse preceptor?
a. Faxing laboratory results to a client's provider
b. Discussing changes in a client's plan of care with his friend who is a nurse on
another unit
c. Describing a client's level of independence to the case manager arranging
home health services
d. Remaining in the room with the client while he reviews his own medical
records - ANSWER-b. Discussing changes in a client's plan of care with his friend
who is a nurse on another unit
In this item, you need knowledge of legal requirements in regard to
confidentiality. Based on this information, you can identify which option
describes an action that indicates a breach of client confidentiality. This is a
negatively worded item that asks you to select the option that indicates an
intervention by the nurse preceptor is warranted. You will learn more about
negatively worded items in Module 4. This item requires critical thinking
because you have to analyze each action in order to interpret the one that
results in a breach of confidentiality. HIPAA is federal legislation that requires
protection of a client's health information and describes the rights and privilege
of clients in regard to privacy and confidentiality. S nurse discussing changes in a
client's plan of care with another nurse on another unit is a breach of
confidentiality. Client information can only be shared with the other health care
,professionals involved in that client's care. The nurse on the other unit should
be directed to the client to request information about changes in the client's
plan of care. This action is not appropriate and requires intervention by the
nurse preceptor.
While collecting data on a client who is immobile, a nurse locates a reddened
area of skin on the left scapula. Which of the following actions should the nurse
take?
a. Reposition of the client every 4 hr
b. Cover the area with a transparent wound barrier
c. Massage areas surrounding the redness
d. Wash the area with hot water every 8 hr - ANSWER-b. Cover the area with a
transparent wound barrier
In this item, you need knowledge of appropriate skin care interventions for
clients who are immobile with indications of a stage I pressure ulcer. This item
requires foundational thinking because you have to recall interventions that are
appropriate for maintaining skin integrity in clients who are immobile. Damage
to tissues caused by continuous pressure is described as a pressure ulcer. The
risk for pressure ulcers can be complicated by factors such as immobility,
inadequate nutrition, bowel and bladder incontinence, decreased mental status,
reduced sensation, increasing age, and excessive body heat. Appropriate care of
pressure ulcers is based on the characteristics and stage of the wound. A wound
that manifests as a reddened area is a stage 1 pressure ulcer. A transparent
wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent
contamination and reduce friction to the area is an appropriate action by the
nurse.
, A nurse is providing discharge education to the parents of a preschooler who is
prescribed acetaminophen (Tylenol) 300 mg every 4 hr as needed. The
acetaminophen liquid suspension that has been prescribed provides 120 mg/5
mL. How many teaspoons should the nurse teach the parents to administer per
dose? - ANSWER-2.5 tsp
In this item, you need knowledge of basic mathematic skills and the formula
used for this type of calculation. Based on your understanding of these
concepts, you can determine the number of teaspoons the nurse should teach
the parents to administer. This item requires critical thinking because you have
to analyze the provided information to determine the dosage, select the
formula, enter data into the formula, and then perform the needed calculations.
STEP 1: What is the dose needed? Dose needed = Desired; 300 mg
STEP 2: What is the dose available? Dose available = Have; 120 mg
STEP 3: Do the units of measurement need to be converted? No (mg=mg).
STEP 4: What is the quantity of the dose available? 5 mL
STEP 5: Set up an equation and solve:
Desired x Quantity / Have = Amount to be given; 300 mg x 5 mL / 120 mg = x mL;
x = 12.5 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 12.5 mL / x;
5x = 12.5; x = 2.5 tsp
A nurse is collecting data on a recently admitted client. Which of the following
techniques should the nurse use to measure tissue perfusion?
a. Determining the client's respiratory rate
b. Measuring the client's chest diameter
c. Obtaining the client's level of oxygen saturation
