ATI Content Mastery Series
1. 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 client who is postoperative following knee arthroplasty is concerned about the
adverse effects of the medication prescribed for pain management. Which of the
following members of the interprofessional care team can assist the client in
understanding the medication's effects? (Select all that apply.)
A. Provider
B. Certified nursing assistant
C. Pharmacist
D. Registered nurse
E. Respiratory therapist - ANS -A, C , D- Correct: The provider, pharmacist, and
registered nurse must be knowledgeable about any medication prescribed for the client,
including its actions, effects, and interactions.
B- Incorrect: it is not within the scope of a certified nursing assistant's duties to counsel
a client about medications
E- Incorrect: Although some analgesics can cause respiratory depression, requiring
assistance from a respiratory therapist is not within this therapist's scope of practice to
counsel the client about medications prescribed by the provider.
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to
use adaptive devices. The nurse caring for the client should initiate a referral to which of
the following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist - ANS -D - Correct: An occupational therapist can assist
clients who have physical challenges to use adaptive devices and strategies to help with
self-care activities.
A- Incorrect: A social worker can coordinate community services to help the client, but
not specifically with self-feeding devices
B- Incorrect: A certified nursing assistant can help the client with feeding, but does not
typically procure adaptive devices for the client
C- Incorrect: A registered dietitian can help with educating the client about meeting
nutritional needs, but cannot help with the client's physical limitations.
1. 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 client who is postoperative following knee arthroplasty is concerned about the
adverse effects of the medication prescribed for pain management. Which of the
following members of the interprofessional care team can assist the client in
understanding the medication's effects? (Select all that apply.)
A. Provider
B. Certified nursing assistant
C. Pharmacist
D. Registered nurse
E. Respiratory therapist - ANS -A, C , D- Correct: The provider, pharmacist, and
registered nurse must be knowledgeable about any medication prescribed for the client,
including its actions, effects, and interactions.
B- Incorrect: it is not within the scope of a certified nursing assistant's duties to counsel
a client about medications
E- Incorrect: Although some analgesics can cause respiratory depression, requiring
assistance from a respiratory therapist is not within this therapist's scope of practice to
counsel the client about medications prescribed by the provider.
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to
use adaptive devices. The nurse caring for the client should initiate a referral to which of
the following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist - ANS -D - Correct: An occupational therapist can assist
clients who have physical challenges to use adaptive devices and strategies to help with
self-care activities.
A- Incorrect: A social worker can coordinate community services to help the client, but
not specifically with self-feeding devices
B- Incorrect: A certified nursing assistant can help the client with feeding, but does not
typically procure adaptive devices for the client
C- Incorrect: A registered dietitian can help with educating the client about meeting
nutritional needs, but cannot help with the client's physical limitations.
