ATI Fundamentals Retake
What do nurses use when preparing change-of-shift report? - ANSStandard handoff
communication tools, such as Introduction, Situation, Background, Assessment,
Recommendation (ISBAR) to facilitate transfers and discharges.
When should discharge planning begin? - ANSOn admission with every patient.
Discharge documentation should include - ANSType of discharge, date & time of discharge,
who went with the client & transportation, where the client went, summary of clients current
condition at discharge, description of any unresolved difficulties and disposition of valuables,
medications brought from home & prescriptions.
Documentation & abbreviations and symbols - ANSBeing accurate & concise is an important
element of documentation. Only abbreviations & symbols approved by The Joint Commission
and the facility are acceptable.
A nurse is discussing the HIPPA privacy rule with nurses during new employee orientation.
Which of the following information should the nurse include? - ANSFamily members should
provide a code prior to receiving client health information, communication of a client can occur
at the nurse's station, a client can request a hard copy of their records and a nurses may
photocopy a client's medical record for transfer to another facility.
A nurse is receiving a providers prescription for morphine by telephone for a client who is
reporting moderate to severe pain. What are the appropriate nursing actions? - ANSRepeat the
details of the prescription back to the provider, have another nurse listen to the telephone
prescription and obtain the providers signature on the prescription within 24 hours.
A problem is an ethical dilemma when - ANSI. A review of scientific data is not enough to solve
it
II. It involves a conflict between two moral imperatives
III. The answer will have a profound effect on the situation and the client
Ethical dilemmas are problems that - ANSinvolve more than one choice and stem from
differences in the values and beliefs of decision makers
Autonomy - ANSthe right to makes one's own personal decisions, even when those decisions
might not be in the that person's best interest.
Beneifience - ANSpositive actions to help others (do good)
Fidelity - ANSagreement to keep promises
, Justice - ANSfairness in care delivery and use of resources
Nonmaleficence - ANSavoidance of harm or injury (do no harm)
Admission inventory of personal items include - ANSclothing, jewelry, money, credit cards,
assistive devices, medications, cell phones and other technology devices, and religious
articles... Nurses should discourage keeping valuables at the bedside.
The nurse will document what related to personal items? - ANSThe nurse will document
communication with the client related to items left within the room and valuables locked in the
facility's safe.
Assault (International Tort) - ANSThe conduct of one person makes another person fearful and
apprehensive.
Example: a nurse threatens to place an NG tube in a client who is refusing to eat.
Battery (International Tort) - ANSIntentional & wrongful physical contract with a person that
involves an injury of offensive contact.
Example: A nurse restrains a client and administers an injection against her wishes.
False Imprisonment (International Tort) - ANSA person is confined or retained against his will.
The nurses uses restraints on a competent client to prevent his leaving the health care facility.
What should the nurse teach older clients about home safety? - ANSTo place electrical cords &
extension cords against a wall behind furniture and use a nonskid mat in the tub or shower &
place a shower chair in the shower and a beside commode if needed.
The client who has heat stroke will have what sign? - ANSHypotension
One of the nurse's responsibility for a client in restraints is to make sure... - ANSthe restraints
are loose enough for range of motion & that there is enough room to fit two fingers between the
restraints & the client.
What is the priority action for a patient with a history of falls? - ANSComplete a fall risk
assessment.
What blood glucose level requires immediate action? - ANS70 mg/dL of less
What are manifestations of hypoglycemia? - ANSMild shakiness, mental confusion, sweating,
palpitations, headache, lack of coordination, blurred vision, seizures, and coma.
What do nurses use when preparing change-of-shift report? - ANSStandard handoff
communication tools, such as Introduction, Situation, Background, Assessment,
Recommendation (ISBAR) to facilitate transfers and discharges.
When should discharge planning begin? - ANSOn admission with every patient.
Discharge documentation should include - ANSType of discharge, date & time of discharge,
who went with the client & transportation, where the client went, summary of clients current
condition at discharge, description of any unresolved difficulties and disposition of valuables,
medications brought from home & prescriptions.
Documentation & abbreviations and symbols - ANSBeing accurate & concise is an important
element of documentation. Only abbreviations & symbols approved by The Joint Commission
and the facility are acceptable.
A nurse is discussing the HIPPA privacy rule with nurses during new employee orientation.
Which of the following information should the nurse include? - ANSFamily members should
provide a code prior to receiving client health information, communication of a client can occur
at the nurse's station, a client can request a hard copy of their records and a nurses may
photocopy a client's medical record for transfer to another facility.
A nurse is receiving a providers prescription for morphine by telephone for a client who is
reporting moderate to severe pain. What are the appropriate nursing actions? - ANSRepeat the
details of the prescription back to the provider, have another nurse listen to the telephone
prescription and obtain the providers signature on the prescription within 24 hours.
A problem is an ethical dilemma when - ANSI. A review of scientific data is not enough to solve
it
II. It involves a conflict between two moral imperatives
III. The answer will have a profound effect on the situation and the client
Ethical dilemmas are problems that - ANSinvolve more than one choice and stem from
differences in the values and beliefs of decision makers
Autonomy - ANSthe right to makes one's own personal decisions, even when those decisions
might not be in the that person's best interest.
Beneifience - ANSpositive actions to help others (do good)
Fidelity - ANSagreement to keep promises
, Justice - ANSfairness in care delivery and use of resources
Nonmaleficence - ANSavoidance of harm or injury (do no harm)
Admission inventory of personal items include - ANSclothing, jewelry, money, credit cards,
assistive devices, medications, cell phones and other technology devices, and religious
articles... Nurses should discourage keeping valuables at the bedside.
The nurse will document what related to personal items? - ANSThe nurse will document
communication with the client related to items left within the room and valuables locked in the
facility's safe.
Assault (International Tort) - ANSThe conduct of one person makes another person fearful and
apprehensive.
Example: a nurse threatens to place an NG tube in a client who is refusing to eat.
Battery (International Tort) - ANSIntentional & wrongful physical contract with a person that
involves an injury of offensive contact.
Example: A nurse restrains a client and administers an injection against her wishes.
False Imprisonment (International Tort) - ANSA person is confined or retained against his will.
The nurses uses restraints on a competent client to prevent his leaving the health care facility.
What should the nurse teach older clients about home safety? - ANSTo place electrical cords &
extension cords against a wall behind furniture and use a nonskid mat in the tub or shower &
place a shower chair in the shower and a beside commode if needed.
The client who has heat stroke will have what sign? - ANSHypotension
One of the nurse's responsibility for a client in restraints is to make sure... - ANSthe restraints
are loose enough for range of motion & that there is enough room to fit two fingers between the
restraints & the client.
What is the priority action for a patient with a history of falls? - ANSComplete a fall risk
assessment.
What blood glucose level requires immediate action? - ANS70 mg/dL of less
What are manifestations of hypoglycemia? - ANSMild shakiness, mental confusion, sweating,
palpitations, headache, lack of coordination, blurred vision, seizures, and coma.
