ATI-F ATI Fundamentals - Set 1 - Part 2

Correct Answer: Notify the provider to clarify the risks

The provider is responsible for explaining a procedure's risks. When the client does not understand, the nurse notifies the provider to clarify before witnessing the signature, ensuring the consent is truly informed. Option b is incorrect because witnessing the signature while the client remains confused defeats the purpose of informed consent. A signature gathered without understanding does not reflect an informed decision, so proceeding would be improper. Option c is incorrect because providing the detailed explanation of surgical risks belongs to the provider, not the nurse. Stepping into that role would exceed the nurse's responsibility and could give the client inaccurate information. Option d is incorrect because canceling the surgery is outside the nurse's authority and skips the needed step. The correct response is to involve the provider so the client's questions are answered before any decision is made.

Correct Answer: A married minor living independently

An emancipated minor, such as a married minor living independently, may consent for their own care. Independence from parents grants the legal standing to provide informed consent without a guardian. Option a is incorrect because a confused older adult may lack the capacity to understand the information required for consent. When understanding is impaired, another authorized person must provide consent on the client's behalf. Option b is incorrect because a school-age child has not reached legal age and is not emancipated. A parent or guardian must give consent for the child, so the child cannot provide it independently in this situation. Option c is incorrect because a sedated client cannot fully understand information or communicate a voluntary decision. Consent must be obtained before sedation, which means this client cannot give valid consent at this moment.

Correct Answer: Document it and inform the care team

The nurse documents the client's advance directive status and ensures the whole care team knows about it. Communicating the living will allows the team to honor the client's stated wishes. Option a is incorrect because advising the client to cancel a living will overrides their right to direct end-of-life care. The nurse supports advance directives rather than discouraging them, so this action is inappropriate. Option b is incorrect because withholding the directive from the team prevents staff from following the client's wishes. The information must be shared so every member can provide care consistent with the living will. Option d is incorrect because basing care on family wishes ignores the client's own documented choices. The living will reflects the client's decisions, which take priority over what family members might prefer for the client.

Correct Answer: Begin cardiopulmonary resuscitation

Without a do-not-resuscitate order, the nurse must start cardiopulmonary resuscitation when a client has no pulse or breathing. Acting immediately gives the client the best chance of survival. Option a is incorrect because waiting for the provider delays lifesaving care during an arrest. With no order to withhold resuscitation, the nurse must act at once rather than pause for someone else to arrive. Option c is incorrect because calling the family wastes critical time while the client has no pulse. Family input does not override the duty to resuscitate when no valid order to withhold care exists. Option d is incorrect because searching for the living will postpones the response a pulseless client urgently needs. Resuscitation must begin first, since no documented order currently directs the nurse to withhold it.

Correct Answer: Report the suspicion as required by law

Nurses are legally obligated to report any suspicion of abuse following facility policy and state law. The nurse does not need proof, only a reasonable suspicion, to make the required report. Option b is incorrect because waiting for confirmation delays protection the client may urgently need. The law requires reporting based on suspicion alone, so holding back until abuse is proven violates that duty. Option c is incorrect because confronting the caregiver is not the nurse's role and could place the client at greater risk. The proper step is to notify the appropriate authorities through the required reporting channel. Option d is incorrect because keeping the concern within the team fails to meet the legal reporting requirement. Suspected abuse must be reported to the designated authority, not simply discussed among coworkers on the unit.

Correct Answer: The client is pacing and speaking loudly

Factual documentation records what the nurse observes without judgment. Describing the client pacing and speaking loudly reports objective behavior, which is more accurate than labeling the client's mood or character. Option a is incorrect because calling the client difficult states an opinion rather than an observation. Such judgmental wording does not describe measurable behavior and has no place in an objective, legal medical record. Option b is incorrect because writing that the client seems anxious interprets a feeling instead of recording evidence. Objective charting describes the specific behaviors observed rather than the nurse's assumption about the client's emotion. Option c is incorrect because describing a bad attitude is a personal judgment, not a fact. The record should capture observable actions, so this label fails the standard for accurate, descriptive documentation of behavior.

Correct Answer: Read the prescription back to the provider

Reading the prescription back to the provider confirms the medication name, dose, route, and time are correct. This write-back step catches errors before the order is carried out, protecting the client. Option a is incorrect because entering an order from memory risks mistakes in the drug, dose, or route. Safe practice requires writing it down and confirming it during the call rather than relying on recall afterward. Option b is incorrect because delaying documentation leaves the order unrecorded and open to error. A telephone prescription should be written and verified immediately so the record stays accurate and the client receives correct care. Option d is incorrect because asking the family to verify a prescription is inappropriate, since relatives are not qualified to confirm medical orders. Verification must occur between the nurse and the provider who gave it.

Correct Answer: Draw a single line through the error

Correct practice is to mark an error with a single line so the original entry stays readable, then follow the facility procedure. This keeps the record honest and legally sound. Option b is incorrect because using correction fluid hides the original entry and raises questions about what was changed. Legal documentation must remain visible and unaltered, so covering an error this way is prohibited. Option c is incorrect because erasing a mistake removes information from a legal record and suggests tampering. The original words must stay legible, which is why erasing is never an acceptable way to correct a chart. Option d is incorrect because leaving a blank space allows someone to add an entry later, which threatens the record's integrity. Nurses avoid blank spaces so the documentation cannot be altered after the fact.

Correct Answer: Recent changes in the client's condition

An effective shift report relays significant objective information and recent changes in medications, treatments, and condition. Sharing the client's recent changes gives the oncoming nurse what they need to continue care. Option a is incorrect because personal opinions do not belong in a professional handoff and can bias the next nurse. The report should stay factual, focusing on the client's status rather than the nurse's impressions. Option c is incorrect because gossip is unrelated to client care and undermines a professional report. Passing along rumors wastes time and adds nothing the oncoming nurse can use to care for the client. Option d is incorrect because criticizing the previous shift turns the report into conflict instead of communication. The handoff exists to transfer accurate clinical information, not to judge how earlier staff performed their work.

Correct Answer: Keep the report out of the medical record

An incident report supports quality improvement and stays separate from the medical record. The nurse documents the facts of the fall in the chart but does not mention the report itself. Option a is incorrect because placing the report in the client's record merges an internal quality document with the legal chart. The two are kept separate, so filing it inside the record is incorrect handling. Option b is incorrect because recording opinions about why the fall happened introduces judgment into a factual document. An incident report should state only what occurred, without speculation about cause or assigning blame. Option c is incorrect because writing in the chart that a report was filed creates a link the facility intends to avoid. The medical record should describe the event itself, not reference the separate incident report.

Correct Answer: Verify the caller's identity using the code

Facilities use an identity code so information reaches only people the client approved. Verifying the caller's identity before sharing anything protects confidentiality and prevents disclosure to an unauthorized person. Option a is incorrect because sharing details because a caller is polite ignores the duty to confirm who they are. Courtesy is not authorization, and disclosing without verification would breach the client's confidentiality. Option b is incorrect because reading chart notes to an unverified caller hands protected information to a possible stranger. The contents of the record are exactly what privacy rules are designed to keep secure. Option d is incorrect because routing the call to the roommate exposes the client's information to someone uninvolved in their care. That transfer spreads private details rather than safeguarding them as the privacy rule requires.

Correct Answer: Log off before leaving the workstation

Logging off before stepping away keeps unauthorized people from viewing or changing protected records under the nurse's access. This simple habit safeguards client information and the nurse's own credentials. Option b is incorrect because leaving the record open lets anyone who passes by read protected health information. An unattended, logged-in screen exposes client data and violates the facility's information security expectations for staff. Option c is incorrect because sharing a password lets another person act under the nurse's identity, erasing accountability. Credentials are personal and must never be given out, even to a trusted coworker on the unit. Option d is incorrect because writing the password near the screen makes it visible to anyone nearby and defeats access controls. Passwords must be kept private rather than posted where others can easily find them.

Correct Answer: Avoid posting any client information or images

Privacy rules prohibit posting client information or images on social media, even without obvious identifiers. The safest guidance is to share nothing about clients or clinical experiences that could expose them. Option a is incorrect because omitting a last name does not make a post safe, because other details can still identify the client. Privacy protection requires sharing no client information at all on social media. Option b is incorrect because a room number can be linked to a specific client and reveals protected information. Posting it online breaches confidentiality just as a name would, so this advice would be wrong to give. Option c is incorrect because hiding a face does not remove identifying features such as tattoos, settings, or surrounding context. Photographs of clients are prohibited on social media regardless of how the image is edited.

Correct Answer: Refrain from accessing the client's record

Only team members directly responsible for a client's care may access that record. Because the nurse is not caring for this client, refraining from opening the record follows the privacy rule. Option a is incorrect because opening a record out of curiosity is an unauthorized access and a privacy violation. Having login ability does not grant permission to view clients the nurse is not caring for. Option c is incorrect because asking a coworker to look up the information still results in unauthorized access to protected data. Routing the request through someone else does not make the snooping acceptable. Option d is incorrect because raising the question with the team spreads interest in private information the nurse has no right to view. The appropriate choice is to leave the unrelated client's record alone.

Correct Answer: Remove and secure the printed list

Printed protected information must be kept secure and out of public view. Removing the list and securing or shredding it prevents unauthorized people from seeing client names and diagnoses. Option a is incorrect because leaving the list in a public area allows anyone passing by to read protected details. Convenience for the next shift does not justify exposing client information to unauthorized eyes. Option b is incorrect because posting names and diagnoses on a board displays protected information to everyone who walks past. Public display of client data is specifically prohibited under the facility's privacy requirements. Option d is incorrect because reading the names aloud broadcasts protected information to anyone within earshot in the public space. The goal is to secure the document, not to announce its contents to others nearby.

Correct Answer: Assisting a stable client with bathing

Bathing a stable client is a routine, low-risk activity of daily living that fits the training of assistive personnel. Delegating it frees the nurse for tasks that require licensure. Option b is incorrect because teaching about new medications requires nursing knowledge and judgment to confirm understanding. This responsibility stays with a licensed nurse and cannot be handed to unlicensed assistive personnel. Option c is incorrect because evaluating a client's response to treatment is part of the nursing process and demands clinical analysis. Assistive personnel are not prepared to make that judgment, so this task is not delegable. Option d is incorrect because developing a care plan relies on assessment and clinical reasoning reserved for the registered nurse. It falls well outside the routine support tasks assistive personnel are trained to perform.

Correct Answer: A licensed practical nurse

Enteral feeding for a client with a head injury carries risk and requires monitoring, so it suits a licensed practical nurse. The skill exceeds what assistive personnel may safely perform. Option a is incorrect because assistive personnel are not trained to manage enteral feedings or watch for complications in a head-injured client. Assigning this task to them would place the client's safety at risk. Option b is incorrect because a family member is not a qualified team member for delivering a clinical feeding. Responsibility for this skilled task belongs to licensed staff, not to relatives present at the bedside. Option c is incorrect because a transport volunteer's role is moving clients, not performing skilled clinical procedures. Enteral feeding requires nursing preparation that a volunteer does not have, making this delegation unsafe for the client.

Correct Answer: Assist the client to shower before nine

Clear delegation specifies the task, the client, and the expected timing. Telling the personnel to assist the client with a shower before a set time gives the direction needed for safe completion. Option a is incorrect because asking for help with morning care sometime leaves the task and timing vague. Without specifics, the personnel cannot know exactly what to do, which weakens safe and reliable delegation. Option b is incorrect because telling personnel to do whatever the client needs shifts judgment onto unlicensed staff. Delegation should define the task clearly rather than leaving the decision about care to the delegatee. Option d is incorrect because instructing them to take care of the client this morning is too broad to follow. Effective communication names the exact task and timeframe instead of offering only a general statement.

Correct Answer: Assign the walk after completing the assessment

Proper supervision means the nurse completes the admission assessment before delegating ambulation. Knowing the client's status first ensures the walk is safe and that assistive personnel act on sound information. Option a is incorrect because delegating the walk before assessing the client risks ambulating someone whose stability is unknown. The assessment must come first so the nurse can judge whether walking is safe to delegate. Option c is incorrect because skipping the assessment removes the information needed to keep the client safe during the walk. Supervision requires evaluating the client before handing the task to unlicensed staff. Option d is incorrect because letting personnel decide when to walk places a clinical judgment on staff who are not prepared for it. The nurse must determine readiness rather than leaving the timing to the delegatee.

Correct Answer: A stable client recovering from routine surgery

Delegating vital signs is appropriate for a stable client whose condition is predictable. A client recovering routinely after surgery fits that circumstance, so assistive personnel can safely measure the readings. Option b is incorrect because a client who just needed naloxone to reverse respiratory depression is unstable and may deteriorate quickly. Such close monitoring requires a nurse's judgment rather than delegation to assistive personnel. Option c is incorrect because sudden chest pain signals a possibly unstable client whose readings could change fast. The nurse should assess this client directly instead of delegating vital signs during a developing problem. Option d is incorrect because a falling blood pressure shows an unstable, changing condition that needs skilled interpretation. Delegating these vital signs would place a deteriorating client with someone unable to act on the findings.