Detailed Answer Key - Created on:/2019 Page 1 DetailedAnswerKey-14 1...

Detailed Answer Key Leadership Practice ATI

Created on:03/25/2019 Page 1

DetailedAnswerKey-14

• A nurse is transcribing a client’s medication prescriptions and is having difficulty reading a written prescription by

the provider. Which of the following nursing actions should the nurse take?

• Clarify the prescription with the client’s family.

Rationale: The nurse should not clarify the medication prescription with the client’s family, because this action could be a breach of confidentiality.

• Interpret the prescription based on the client’s health history.

Rationale: The nurse should not interpret the medication prescription based on the client’s health history, because incorrect information may result.

• Ask the pharmacist for clarification of the prescription.

Rationale: The nurse should not ask the pharmacist for clarification of the prescription, because incorrect information may result.

• Contact the provider to clarify the prescription.

Rationale: The nurse should contact the provider for clarification of the prescription to confirm the correct interpretation of the prescription.

• A nurse on a quality control committee is evaluating the results of recently implemented measures designed to

reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?

• Establish a benchmark to identify a standard of performance.

Rationale: A benchmark measures the practices of an organization against a best–performing organization in order to develop improvement of performance. It is used as a tool to determine the desired standard of performance.

• Compare the number of medication errors before and after the action was implemented.

Rationale: Preimplementation and postimplementation statistics for medication errors will provide information to determine the success of the actions.

• Provide the staff with a questionnaire to quantify staff satisfaction with the changes.

Rationale: A questionnaire that determines staff satisfaction can provide a means of communication regarding the new practice, but it does not measure the success of the new measures.

• Conduct a study about the time and money costs of implementing the change.

Rationale: A study about the time and money costs of the effort is useful for comparing the success of the changes to the cost required to make them. However, this will not measure how successful the changes were in reducing medication errors.

Detailed Answer Key Leadership Practice ATI

Created on:03/25/2019 Page 2

• A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the

following assignments is an example of overdelegation?

• Assigning two assistive personnel (AP) to ambulate all clients

Rationale: Assigning two APs to ambulate 10 clients follows the rights of delegation and expectations of the APs. It is not an example of overdelegation.

• Assigning a new graduate nurse to perform a wet-to-dry dressing change

Rationale: Assigning a new graduate nurse to perform a wet-to-dry dressing change follows the rights of delegation and expectations of the nurse. It is not an example of overdelegation.

• Assigning the most efficient AP to perform glucometer monitoring for each client

Rationale: Asking the most efficient AP to perform glucometer testing based on her efficiency in performing this task is an example of overdelegation. This can result in the AP becoming overworked and tired, thus decreasing productivity.

• Assigning the most competent RN to perform a central line dressing change

Rationale: Assigning the most competent RN to perform a central line dressing change follows the rights of delegation and expectations of the nurse. It is not an example of overdelegation.

• A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most

from the nurse acting as an advocate?

• A client who has previously undergone a procedure that is to be performed for a second time

Rationale: The nurse supports the client in this situation, but it is not an example of a client benefitting most from the nurse acting as an advocate.

• A client who has been educated on treatment options and chooses alternative treatments

Rationale: The nurse supports the client in this situation, but it is not an example of a client benefitting most from the nurse acting as an advocate.

• A client who makes an informed decision not to participate in chemotherapy treatment

Rationale: The nurse supports the client in this situation, but it is not an example of a client benefitting most from the nurse acting as an advocate.

• An older adult client who has no family and is uncertain about moving to assisted living

Rationale: The nurse acts as an advocate by ensuring the client has correct information to make an appropriate decision in selecting needed services. This is an example of a client benefitting most from the nurse acting as an advocate.

• A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and

time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?

Detailed Answer Key Leadership Practice ATI

Created on:03/25/2019 Page 3

• The client's partner

Rationale: Legal decisions regarding health care must be made by a competent person or the person holding the durable power of attorney.

• The client

Rationale: If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent.

• The client's daughter, who is the primary caregiver

Rationale: Although the primary caregiver cares for the client, legal decisions regarding health care must be made by a competent person or the person holding the durable power of attorney. Caring for a client does not give the client's daughter legal authority regarding health care decisions.

• The client's son, who has a durable power of attorney

Rationale: A durable power of attorney for health care is a legal document that designates an individual authorized to make health care decisions for a client who is unable. The client's son should be familiar with the client's wishes.

• A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several

bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first?

• Document the bruises in the client's chart.

Rationale: The nurse should document the bruises in the client’s chart after providing care to comply with legal guidelines; however, there is another action the nurse should take first.

• Report the findings to a supervisor.

Rationale: The greatest risk to this client is further injury from continued abuse; therefore, the first action the nurse should take is to report the findings to a supervisor. Nurses are required to report suspected cases of child and older adult abuse.

• Provide the client with a crisis hotline number.

Rationale: The nurse should provide the client and family with a crisis hotline number in case emergency help is needed; however, there is another action the nurse should take first.

• Discuss respite care with the client’s family.

Rationale: The nurse should discuss respite care with the client’s family to prevent caregiver role strain; however, there is another action the nurse should take first.

• A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following

Detailed Answer Key Leadership Practice ATI

Created on:03/25/2019 Page 4

tasks should the nurse delegate to the LPN? (Select all that apply.)

• Provide discharge instructions to a confused client's spouse.
• Obtain vital signs from a client who is 6 hr postoperative.
• Administer a tap-water enema to a client who is preoperative.
• Initiate a plan of care for a client who is postoperative from an appendectomy.
• Catheterize a client who has not voided in 8 hr.

Rationale: Providing discharge instructions to a confused client's spouse is incorrect. The nurse is responsible for delegating a task to the person who has proper training and skill. Client education is the responsibility of the registered nurse.Obtaining vital signs from a client who is 6 hr postoperative is correct. Obtaining is a task that is appropriate to the education and skills of an LPN.Administering a tap-water enema to a client who is preoperative is correct.Administering a tap-water enema is a task that is appropriate to the education and skills of an LPN.Initiating a plan of care for a client who is postoperative from an appendectomy is incorrect.Planning care is the responsibility of the registered nurse.Catheterizing a client who has not voided in 8 hr is correct. Urinary catheterization is a task that is appropriate to the education and skills of an LPN.

• A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following

actions should the nurse take?

• Inform the staff member of her appraisal time for that day prior to change-of-shift report.

Rationale: The charge nurse should give the employee 2 to 3 days advance notice of the appraisal conference time so the staff member can be prepared for the interview.

• Schedule the appraisal interview as early in the shift as possible.

Rationale: The charge nurse should schedule the appraisal interview at a time when it is not busy at work and when it is convenient for the staff member so she can have time to fully participate in the conference.

• Provide a chair directly across the desk for the staff member to sit in.

Rationale: The charge nurse should arrange the chairs so they are side by side to denote collegiality.Placing the chairs across from one another denotes a power status position.

• Provide the staff member with a copy of the appraisal form in advance.

Rationale: The charge nurse should ensure the staff member knows the standards by which her work will be evaluated and that she has a copy of the appraisal form.

• A nurse has completed an informed consent form with a client. The client then states, “I have changed my mind and

do not want to have the procedure done.” Which of the following actions should the nurse take?

• Remind the client that a signed informed consent form is a legally binding document.

Rationale: