ATI Content Mastery Series
A charge nurse is assigning client care for four clients. Which of the following tasks
should the nurse assign to a PN?
A. Creating a plan of care for a client who is recovering following a stroke.
B. Assessing a pressure injury on the client who is on bed rest.
C. Providing nasopharyngeal suctioning for a client who has pneumonia.
D. Teaching a client who has asthma to use a metered-dose inhaler (MDI). -
------------ANS: C- Correct: Providing nasopharyngeal suctioning is within the scope
of practice of the PN.
A, B, D- Incorrect: Creating a plan of care, Assessing a pressure injury, and Teaching
clients requires professional nursing knowledge, skills, and judgement of an RN.
A charge nurse is observing a newly licensed nurse care for a client who reports
pain. The nurse checked the client's MAR and noted that the last dose of pain
medication was 6hrs ago. The prescription reads every 4hr PRN for pain. The nurse
administered the medication and checked with the client 40 mins later, when the
client reported improvement. The newly licensed nurse left out which of the following
steps of the nursing process?
A.. Assessment
B. Planning
C. Intervention
D. Evaluation - ------------ANS: A- Correct: The newly licensed nurse should have
used the assessment step of the nursing process by asking the client to evaluate the
severity of pain on a 0 to 10 pain scale. The nurse also should have asked about the
characteristics of the pain and assessed for any changes that might have contributed
to worsening of the pain.
,B- Incorrect: The newly licensed nurse used the planning step of the nursing process
when deciding that it was the right time to administer the medication.
C- Incorrect: The newly licensed nurse used the implementation step of the nursing
process when administering the medication.
D- Incorrect: The newly licensed nurse used the evaluation step of the nursing
process when checking the effectiveness of the pain medication.
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. - ------------ANS: B, C- Correct:
Documentation must confirm correct sequence of events for day and time and 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.
A charge nurse is reviewing the steps of the nursing process with a group of nurses.
Which of the following data should the charge nurse identify as objective data?
(Select all that apply.)
,A. Respiratory rate is 22/min with even, unlabored respirations
B. The client's partner states, "They said they hurt after walking about 10 mins."
C. The client's pain rating is 3 on a scale of 0 to 10.
D. The client's skin is pink, warm, and dry.
E. The assistive personnel reports that the client walked with a limp. - ------------ANS:
A, D, E- Correct: Objective data includes information that can be measured or
observed (seen).
B, C- Incorrect: Subjective data includes a client's reported manifestations, even if a
secondary source gave the nurse the information.
A charge nurse is reviewing with a newly hired nurse the difference in manifestations
of 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 - ------------ANS: A, B, E- Correct: Fever,
Malaise, and Increase in pulse and respiratory rate indicates that the infection is
affecting the whole body, and therefore systemic.
C, D- Incorrect: Edema, pain or tenderness are manifestations of localized infection.
A charge nurse is talking with a newly licensed nurse and is reviewing nursing
interventions that do not require a provider's prescription. Which of the following
interventions should the charge nurse include? (Select all that apply.)
, A. Writing a prescription for morphine sulfate as needed for pain
B. Inserting a nasogastric (NG) tube to relieve gastric distention
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hrs to reduce pressure injury risk - ------------ANS:
C, D, E- Correct: Muscle relaxation is an appropriate nursing-initiated intervention for
stress relief, bathing is a routine nursing care procedure, and repositioning is an
appropriate nursing- initiated intervention. Unless there is a contraindication for a
specific client.
A, B- Incorrect: A prescription from the provider is needed for administer medication
and insertion of a NG tube. After obtaining a prescription for PRN medication, the
nurse has flexibility to determine when to administer the mediation.
A client who had a cerebrovascular accident has persistent problems with
dysphagia. The nurse caring for the client should initiate a referral with which of the
following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Occupational therapist
D. Speech-language pathologist - ------------ANS: D- Correct: A speech-language
pathologist can initiate specific therapy for clients who have difficulty with feeding
due to the swallowing difficulties.
A- Incorrect: A social worker can coordinate community services to help the client,
but not specifically with dysphagia.
B- Incorrect: A certified nursing assistant can help the client with feeding, but cannot
assess and treat dysphagia.
C- Incorrect: An occupational therapist can assist clients who have motor challenges
to improve abilities with self-care and work, but cannot assess and treat dysphagia.
A charge nurse is assigning client care for four clients. Which of the following tasks
should the nurse assign to a PN?
A. Creating a plan of care for a client who is recovering following a stroke.
B. Assessing a pressure injury on the client who is on bed rest.
C. Providing nasopharyngeal suctioning for a client who has pneumonia.
D. Teaching a client who has asthma to use a metered-dose inhaler (MDI). -
------------ANS: C- Correct: Providing nasopharyngeal suctioning is within the scope
of practice of the PN.
A, B, D- Incorrect: Creating a plan of care, Assessing a pressure injury, and Teaching
clients requires professional nursing knowledge, skills, and judgement of an RN.
A charge nurse is observing a newly licensed nurse care for a client who reports
pain. The nurse checked the client's MAR and noted that the last dose of pain
medication was 6hrs ago. The prescription reads every 4hr PRN for pain. The nurse
administered the medication and checked with the client 40 mins later, when the
client reported improvement. The newly licensed nurse left out which of the following
steps of the nursing process?
A.. Assessment
B. Planning
C. Intervention
D. Evaluation - ------------ANS: A- Correct: The newly licensed nurse should have
used the assessment step of the nursing process by asking the client to evaluate the
severity of pain on a 0 to 10 pain scale. The nurse also should have asked about the
characteristics of the pain and assessed for any changes that might have contributed
to worsening of the pain.
,B- Incorrect: The newly licensed nurse used the planning step of the nursing process
when deciding that it was the right time to administer the medication.
C- Incorrect: The newly licensed nurse used the implementation step of the nursing
process when administering the medication.
D- Incorrect: The newly licensed nurse used the evaluation step of the nursing
process when checking the effectiveness of the pain medication.
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. - ------------ANS: B, C- Correct:
Documentation must confirm correct sequence of events for day and time and 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.
A charge nurse is reviewing the steps of the nursing process with a group of nurses.
Which of the following data should the charge nurse identify as objective data?
(Select all that apply.)
,A. Respiratory rate is 22/min with even, unlabored respirations
B. The client's partner states, "They said they hurt after walking about 10 mins."
C. The client's pain rating is 3 on a scale of 0 to 10.
D. The client's skin is pink, warm, and dry.
E. The assistive personnel reports that the client walked with a limp. - ------------ANS:
A, D, E- Correct: Objective data includes information that can be measured or
observed (seen).
B, C- Incorrect: Subjective data includes a client's reported manifestations, even if a
secondary source gave the nurse the information.
A charge nurse is reviewing with a newly hired nurse the difference in manifestations
of 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 - ------------ANS: A, B, E- Correct: Fever,
Malaise, and Increase in pulse and respiratory rate indicates that the infection is
affecting the whole body, and therefore systemic.
C, D- Incorrect: Edema, pain or tenderness are manifestations of localized infection.
A charge nurse is talking with a newly licensed nurse and is reviewing nursing
interventions that do not require a provider's prescription. Which of the following
interventions should the charge nurse include? (Select all that apply.)
, A. Writing a prescription for morphine sulfate as needed for pain
B. Inserting a nasogastric (NG) tube to relieve gastric distention
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hrs to reduce pressure injury risk - ------------ANS:
C, D, E- Correct: Muscle relaxation is an appropriate nursing-initiated intervention for
stress relief, bathing is a routine nursing care procedure, and repositioning is an
appropriate nursing- initiated intervention. Unless there is a contraindication for a
specific client.
A, B- Incorrect: A prescription from the provider is needed for administer medication
and insertion of a NG tube. After obtaining a prescription for PRN medication, the
nurse has flexibility to determine when to administer the mediation.
A client who had a cerebrovascular accident has persistent problems with
dysphagia. The nurse caring for the client should initiate a referral with which of the
following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Occupational therapist
D. Speech-language pathologist - ------------ANS: D- Correct: A speech-language
pathologist can initiate specific therapy for clients who have difficulty with feeding
due to the swallowing difficulties.
A- Incorrect: A social worker can coordinate community services to help the client,
but not specifically with dysphagia.
B- Incorrect: A certified nursing assistant can help the client with feeding, but cannot
assess and treat dysphagia.
C- Incorrect: An occupational therapist can assist clients who have motor challenges
to improve abilities with self-care and work, but cannot assess and treat dysphagia.
