ATI FUNDAMENTALS PROCTORED EXAM
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up
to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only
when the client is supine in bed. The nurse telephoned the physical therapist about the
difficulties containing the drainage from the fistula, so the therapist didn't ambulate the
client today. The client sat in a chair during lunch w/an absorbent pad over the fistula.
The client ate all the food on her tray. The wound care nurse confirmed that she will see
the client later today. The client states she feels frustrated at not having physical therapy,
but the nurse thinks the client welcomed having a day to rest. Which of the following
information should the nurse include in the change-of-shift report? Select all that apply.
A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the client stands.
C. The client seemed to welcome having a "day off" from physical therapy
D. The wound care nurse will see the client later today
E. The client ate all the food on her lunch tray
A, B, D
A nurse is receiving a provider's prescription by telephone for morphine for a client who
is reporting moderate to severe pain. Which of the following nursing actions are
appropriate? Select all that apply.
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain the prescriber's signature on the prescription within 24hrs
D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone A, B, C
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days.
He states that it is difficult to prepare adequate nutritious meals at home for just 1
person. To which of the following members of the health care team should the nurse
refer him?
A. Registered dietitian
B. Occupational therapist
C. Physical therapist
D. Social worker
D. social worker
, Rational: A social worker can make arrangements for a meal delivery service to provide
nutritious meals daily, or recommend a congregate meal site near the client's home
lO
M
o
A
R
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P
S
D
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6
4
5
7
2
2
2
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use
adaptive devices. The nurse caring for the client should initiate a referral w/which of the
following members of the inter-professional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist E. Registered dietitian
D. Occupational therapist
Rational: An occupational therapist can assist clients who have physical challenges to
use adaptive devices & strategies to help w/self-care activities
Can an RN delegate to the LPN to provide tracheostomy care to a client with
pneumonia? 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 a 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
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
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up
to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only
when the client is supine in bed. The nurse telephoned the physical therapist about the
difficulties containing the drainage from the fistula, so the therapist didn't ambulate the
client today. The client sat in a chair during lunch w/an absorbent pad over the fistula.
The client ate all the food on her tray. The wound care nurse confirmed that she will see
the client later today. The client states she feels frustrated at not having physical therapy,
but the nurse thinks the client welcomed having a day to rest. Which of the following
information should the nurse include in the change-of-shift report? Select all that apply.
A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the client stands.
C. The client seemed to welcome having a "day off" from physical therapy
D. The wound care nurse will see the client later today
E. The client ate all the food on her lunch tray
A, B, D
A nurse is receiving a provider's prescription by telephone for morphine for a client who
is reporting moderate to severe pain. Which of the following nursing actions are
appropriate? Select all that apply.
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain the prescriber's signature on the prescription within 24hrs
D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone A, B, C
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days.
He states that it is difficult to prepare adequate nutritious meals at home for just 1
person. To which of the following members of the health care team should the nurse
refer him?
A. Registered dietitian
B. Occupational therapist
C. Physical therapist
D. Social worker
D. social worker
, Rational: A social worker can make arrangements for a meal delivery service to provide
nutritious meals daily, or recommend a congregate meal site near the client's home
lO
M
o
A
R
c
P
S
D
|
6
4
5
7
2
2
2
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use
adaptive devices. The nurse caring for the client should initiate a referral w/which of the
following members of the inter-professional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist E. Registered dietitian
D. Occupational therapist
Rational: An occupational therapist can assist clients who have physical challenges to
use adaptive devices & strategies to help w/self-care activities
Can an RN delegate to the LPN to provide tracheostomy care to a client with
pneumonia? 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 a 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
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
