a charge nurse is planning care for a group of clients on a medical surgical unit which of the following tasks should the nurse delegate to an assisti
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

2. A charge nurse is discussing HIPAA with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching as an example of a HIPAA violation?

Correct answer: D

Rationale: The correct answer is D. Emailing client information through an unencrypted server is a HIPAA violation because it can lead to data breaches. Choices A, B, and C do not violate HIPAA. Posting the name of the nurse providing care on a client's communication board does not disclose sensitive health information. Discussing the client's new medication with a hospital pharmacist is a routine healthcare practice. Faxing requested medical information for a client who is transferring to another facility is a secure way to transmit healthcare data.

3. After surgery, a patient is experiencing pain. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to assess the patient's pain using a pain scale. This is the priority action because it allows the nurse to obtain an objective measure of the patient's pain intensity. By accurately assessing the pain level, the nurse can determine the appropriate intervention, which may include administering pain medication as prescribed (choice A) or offering non-pharmacological pain relief methods (choice C). Reassessing the patient's pain level after 30 minutes (choice D) is important but comes after the initial assessment to evaluate the effectiveness of the interventions implemented.

4. A healthcare professional is reviewing the notes written by a previous shift. Which documentation reflects proper guidelines?

Correct answer: B

Rationale: The correct answer is B. Proper documentation should include objective observations and detailed notes to ensure continuity of care. Choice A is incorrect because incomplete entries can lead to gaps in information and compromise patient care. Choice C is not completely accurate as corrections should be made in a manner that does not obscure the original entry but does not necessarily require a signature. Choice D is incorrect as entries should ideally be corrected by the original author to maintain accountability and accuracy.

5. A healthcare provider is reviewing the medical record of a client who has a new prescription for cimetidine. Which of the following laboratory findings should the healthcare provider identify as the priority to report to the provider?

Correct answer: C

Rationale: An elevated AST level is indicative of liver damage, which is the priority finding to report to the provider when administering cimetidine. Elevated liver enzymes can be a sign of liver toxicity or damage. Monitoring liver function is crucial when using cimetidine, as it can sometimes lead to hepatotoxicity. The other laboratory findings are within normal ranges and not directly associated with cimetidine administration.

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