ATI Course Work
Week 1 Review
Please describe the five rights of delegation including an example of each:
1. Right task- Only certain tasks can be delegated to certain personnel. Never delegate a
task requiring nursing judgment, patient education, or clinical reasoning. The task must
require little supervision and be relatively noninvasive.
Example: Delegate to an AP to assist a client who has pneumonia to use a bedpan.
2. Right circumstance- The patient must be stable and complexity of care must be
considered.
Example: Delegate to an AP to measure the vital signs of a client whom is postoperative and
stable.
3. Right person- The individual you delegate to must be trained to perform that task and must
have the necessary skill base, LPN vs AP.
Example: Delegate to a PN to administer enteral feedings to a client who has a head injury.
4. Right Direction/Communication- Provide comprehensive and specific instructions when
delegating, i.e. identifying the task, when you want it accomplished, and method for reporting.
Example: Delegate to an AP to assist Ms. Lee in room 219 with a shower before 0930.
5. Right Supervision/Evaluation- The RN must provide supervision either directly or indirectly
by assigning supervision to another licensed nurse. Intervene if necessary and evaluate the
client. Provide feedback to the AP or LPN.
Example: Delegate to an AP to assist with ambulating a client after the RN completes the
admission assessment.
List four (4) examples of a primary skin lesion including description and example of
each. Provide an example of appropriate documentation of the integumentary system.
1. Macule – nonpalpable skin color change smaller than 1 cm. (Freckle, petechiae)
2. Papule – palpable circumscribed solid elevation of skin smaller than 1 cm. (elevated
nevus)
3. Nodule – palpable circumscribed deep firm 1-2 cm. (wart)
4. Vesicle – serous fluid-filled, smaller than 1 cm. (blister, herpes simplex, varicella)
Documentation: Skin pink, warm, and dry. 0.5 cm brown papule on distal left forearm.
What are three (3) of the provider’s responsibility for obtaining an informed consent?
1. Informing the client of the risks and benefits of the procedure.
2. Informing the client of alternatives.
3. Explaining the purpose and providing a complete description of the procedure.
Identify and explain the three (3) types of torts. Provide one (1) example for each type
of tort.
1. Unintentional:
Malpractice – Involves misconduct or lack of skill in carrying out professional
responsibilities and results in death of the client.
Negligence – Unintentional failure to perform an act that a reasonable person would or
would not perform in similar circumstances.
Example: Failure of the RN to implement safety measures for a patient on restraint or
seclusion orders.
2. Quasi-intentional:
Breach of confidentiality – release of information to an unauthorized person without the
patient’s given consent.
Defamation of character – publication of false statements that result in damage to a
person’s reputation.
Example: The RN tells a coworker that patient X is having sex with the doctor.
3. Intentional:
False imprisonment – keeping a patient confined or restrained against his/her will.
Battery – intentional touching without consent.
Assault – threat to cause harm.
Example: RN threatens a patient with restraints for refusing to take medication.
List three (3) actions to take during the analysis or data collection step.
1. Recognize patterns or trends.
2. Compare the data with expected standards or reference ranges.
3. Arrive at a conclusion to guide nursing care.
The physician prescribes meperidine 25 mg IM now for a client's pain. Available:
Meperidine 100 mg/mL How much meperidine will the nurse administer?
0.25mL
What action should a nurse implement to prevent clogging of the NG tube after
medication administration?
Flush the tubing before and after each medication with 15-30 mL of water. Flush with another
15-30 mL sterile water after instilling all the medications.
A client’s lab values indicate a serum sodium level of 150 mEq/L. How could this affect
the client’s vital signs?
This could make the patient tachycardic and increase contractility of the heart. High levels of
sodium likely mean high fluid levels, and if this is the case, the patient’s blood pressure may
be elevated. This shift in fluid would cause dehydration of the cells.
A nurse is caring for a client with pneumonia that is experiencing dyspnea. How should
the nurse position this client and why?
A high side lying position to promote accessory muscle breathing.
A nurse is teaching a caregiver about the use of a vacuum-assisted closure system.
How should the nurse instruct the caregiver to apply the foam strips?
Insert the foam strips into the wound with the drainage mechanism on top. Then it is covered
with a transparent adhesive membrane to seal the wound and facilitate drainage. The foam is
important because it prevents localized areas of high pressure (and subsequent tissue
damage) that occur through direct contact of the vacuum device.
