2023 ATI RN Leadership Proctored Exam Version 1-3 With Answers-205 Solved Questions

ATI RN Leadership Proctored Exam 2023 Version 1, 2, 3,4 |Latest Update
written by gitonga
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients
should The nurse recommend for an interdisciplinary care conference?
A. A client who is at 35 weeks of gestation and has a biophysical profile of 6.
B. A client who is at 28 weeks of gestation and has gestational diabetes controlled by diet.
C. A client who is at 20 weeks of gestation with a history of preterm labor in a previous
pregnancy.
D. A client who is at 32 weeks of gestation and has mild hypertension, with no other
complications.
Answer: A. A client who is at 35 weeks of gestation and has a biophysical profile of 6.
A nurse is preparing to discharge a client who has end stage heart failure. The clients partner
tells The nurse she can no longer handle caring for the client. Which of the following actions
should the nurse take?
A. Contact the case manager to discuss discharge options and resources available for home
care.
B. Encourage the partner to seek counseling to cope with caregiving stress.
C. Advise the partner to reach out to family members for support.
D. Discharge the client without further discussion, as they are stable.
Answer: A. Contact the case manager to discuss discharge options and resources available
for home care.
A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of
asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which
of the following referrals should the nurse recommend?
A. Social Worker
B. Respiratory Therapist
C. Nutritionist
D. Paediatrician
Answer: A. Social Worker

A nurse is supervising assistive personnel who’s feeding a client with dysphagia. Which of
the following actions by the AP should the nurse identify as correct technique?
A. Instructing the client to place their chin to their chest while swallowing.
B. Allowing the client to eat in a supine position.
C. Giving the client large bites of food to minimize mealtime duration.
D. Providing the client with thin liquids to drink.
Answer: A. Instructing the client to place their chin to their chest while swallowing.
A nurse is providing an in-service about client rights for a group of nurses. Which of the
following statements should the nurse include in the in-service?
A. “A nurse can disclose information to a family member with the client’s permission.”
B. “A nurse must always keep client information confidential, even if it is not requested.”
C. “A nurse can share any information with a family member as long as they are present
during the appointment.”
D. “A nurse should inform family members about the client’s condition without needing the
client’s consent.”
Answer: A. “A nurse can disclose information to a family member with the client’s
permission.”
A nurse is preparing to discharge a client who requires home oxygen. The equipment
company has not yet delivered the oxygen tank. Which of the following action should the
nurse take?
A. Contact social services about the delivery of the oxygen equipment.
B. Instruct the client to pick up the oxygen tank from the facility.
C. Notify the healthcare provider about the delay in delivery.
D. Advise the client to go without oxygen until it arrives.
Answer: C. Notify the healthcare provider about the delay in delivery.
A nurse is preparing a client for surgery. The client has signed the consent form but tells the
nurse that she has reconsidered because she is worried about the pain. Which of the following
response by the nurse is appropriate?
A. "I understand, and it’s not too late to change your mind."
B. "You shouldn't worry about pain; the surgery is routine and safe."
C. "Once you sign the consent form, you can't change your mind."

D. "Pain is part of the process; you will manage it afterward."
Answer: A. "I understand, and it’s not too late to change your mind."
A nurse in a long-term care facility is caring for a client and witnessed the assistive personnel
position him in bed with excessive force. Which of the following actions should the nurse
take?
A. Contact the nurse manager.
B. Discuss the incident with the assistive personnel.
C. Document the incident in the client’s chart.
D. Report the incident to the client's family.
Answer: A. Contact the nurse manager.
A nurse is assessing a client who has meningitis. Which of the following finding should the
nurse report to the provider immediately?
A. Decreased level of consciousness.
B. Mild headache.
C. Sensitivity to light.
D. Nausea and vomiting.
Answer: A. Decreased level of consciousness.
A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other
clients, and visitors. Which action should the nurse take?
A. Administer sedatives.
B. Keep the client in her room with the door closed.
C. Contact family members to come visit with the client.
D. Place the client in a wheelchair with a lap tray.
Answer: C. Contact family members to come visit with the client.
A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse
is having trouble focusing and had difficulty completing care for his assigned client. Which
of the following intervention is appropriate
A. Recommend that he take time to plan at the beginning of his shift.
B. Suggest that he ask the charge nurse to assign fewer clients.
C. Encourage him to work faster to complete his tasks.

D. Advise him to avoid asking questions to maintain his independence.
Answer: A. Recommend that he take time to plan at the beginning of his shift.
A nurse is preparing to delegate bathing and turning of a newly admitted client who has endstage bone cancer to an experienced AP. Which of the following assessment should the nurse
make before delegating care?
A. Has data been collected about specific client needs related to turning?
B. Is the AP familiar with the client's medical history?
C. Does the AP have experience with clients who have cancer?
D. Has the AP received training on infection control practices?
Answer: A. Has data been collected about specific client needs related to turning?
A nurse is participating in the development of a disaster management plan for a hospital. The
nurse should recognize that which of the following resources is the highest priority to have
available in response to a bioterrorism event?
A. A sufficient supply of personal protective equipment.
B. A stockpile of antibiotics.
C. A trained response team.
D. A communication plan for public information.
Answer: A. A sufficient supply of personal protective equipment.
A nurse manger observes an assistive personnel incorrectly transferring a client to the
Bedside commode. Which of the following actions should the nurse take first?
A. Help the AP transfer the patient.
B. Discuss the correct transfer technique with the AP after the transfer.
C. Document the incident in the incident report.
D. Inform the charge nurse about the incident.
Answer: A. Help the AP transfer the patient.
A nurse manager is leading a discussion about ethical dilemmas. Which of the following
situations should the nurse manager include as an example of an ethical dilemma?
A. A nurse witnesses another nurse administer incorrect medication.
B. A visitor experiences minor burns at a facility after receiving treatment.
C. A parent wants a 14-year-old adolescent to receive radiation treatment against his will.

D. A client receives an operation on the wrong side of the body.
Answer: C. A parent wants a 14-year-old adolescent to receive radiation treatment against his
will.
A nurse is caring for a client who requests information about the prevalence of Tay-Sachs
disease. Which of the following resources should the nurse use to obtain this information?
A. An evidence-based nursing journal.
B. A local newspaper article.
C. A general health website.
D. A medical textbook.
Answer: A. An evidence-based nursing journal.
A nurse is orienting a newly licensed nurse about client confidentiality. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "I should encrypt personal health information when sending email."
B. "It's acceptable to share client information with coworkers casually."
C. "I can discuss client information on social media as long as I don’t use names."
D. "Client information can be shared with family members without consent."
Answer: A. "I should encrypt personal health information when sending email."
A nurse in the emergency department is assessing a client who is unconscious following a
motor vehicle crash. The client requires immediate surgery. Which of the following actions
should the nurse take?
A. Transport the client to the operating room without verifying informed consent.
B. Attempt to obtain informed consent from the client before transport.
C. Contact the family to obtain consent for the surgery.
D. Document the need for surgery in the client's chart before transport.
Answer: A. Transport the client to the operating room without verifying informed consent.
A nurse enters a client's room to witness an informed consent for a gastroscopy. The client
states he does not understand the procedure. Which of the following actions should the nurse
take?
A. Inform the provider that the client requires clarification about the procedure.
B. Explain the procedure to the client in detail.

C. Ask the client to sign the consent form anyway.
D. Tell the client that he will be fine and it’s a simple procedure.
Answer: A. Inform the provider that the client requires clarification about the procedure.
A case manager is preparing a discharge plan for a client following coronary artery bypass
grafting surgery. Which of the following client issues should the nurse address first?
A. Inadequate food supply.
B. Lack of transportation to follow-up appointments.
C. Need for home health care services.
D. Concerns about medication management.
Answer: A. Inadequate food supply.
A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the
following diseases should the nurse report to the state health department?
A. Pertussis.
B. Influenza.
C. Chickenpox.
D. Seasonal allergies.
Answer: A. Pertussis.
A nurse is preparing to complete an incident report regarding a medication error. The
following actions should be planned to take:
A. Place a copy of the completed report in the client’s medical record.
B. Make a copy of the incident report for personal record keeping.
C. Include the time the medication error occurred in the report.
D. Identify the medication name and the dose administered to the client in the report.
E. Obtain an order from the client’s provider to complete the report.
Answer: C. Include the time the medication error occurred in the report.
D. Identify the medication name and the dose administered to the client in the report.
A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the
following clients should be assigned to an RN who has floated from a medical-surgical unit?
A. A primigravida client who is 1 day postoperative following a cesarean section and has a
stable condition.

B. A client in active labor with a history of complications.
C. A client with gestational hypertension who requires frequent monitoring.
D. A postpartum client experiencing heavy bleeding.
Answer: A. A primigravida client who is 1 day postoperative following a caesarean section
and has a stable condition.
A nurse in the emergency department is preparing to care for a client who arrived via
ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following
actions should the nurse take?
A. Proceed with treatment without obtaining written consent.
B. Attempt to obtain verbal consent from the client.
C. Wait until the client is oriented to begin treatment.
D. Notify the family to obtain consent before treatment.
Answer: A. Proceed with treatment without obtaining written consent.
A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a
licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks
should the nurse assign to the LPN?
A. Reinforcing dietary teaching with a client who has heart disease.
B. Assisting a client with activities of daily living (ADLs).
C. Taking vital signs of a stable client.
D. Documenting intake and output for a client.
Answer: A. Reinforcing dietary teaching with a client who has heart disease.
A nurse working on a medical-surgical unit is managing the care of four clients. The nurse
should schedule an interdisciplinary conference for which of the following clients?
A. A client who is receiving heparin and has an APTT of 34 seconds.
B. A client with a wound infection requiring IV antibiotics.
C. A client who is scheduled for discharge after a routine procedure.
D. A client experiencing chronic pain who requires a medication adjustment.
Answer: A. A client who is receiving heparin and has an APTT of 34 seconds.
A nurse enters the hallway and discovers a visitor looking at a client's medical information on the
computer. Which of the following actions should the nurse take first?

A. Close the documentation program on the computer.

B. Ask the visitor to leave the area.
C. Inform the charge nurse about the situation.
D. Discuss the importance of confidentiality with the visitor.
Answer: A. Close the documentation program on the computer.
A nurse is assessing an older adult client who was brought to the emergency department by
his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which
of the following actions should the nurse take?
A. Ask the client’s son to go to the waiting area.
B. Conduct the assessment with the son present for support.
C. Document the son’s account of the fall in the medical record.
D. Notify the social worker to evaluate the situation.
Answer: A. Ask the client’s son to go to the waiting area.
A nurse is caring for a client who is unconscious and whose partner is their healthcare
surrogate. The partner wishes to discontinue the client’s feeding tube, but another family
member tells the nurse they want the client to continue receiving treatment. Which of the
following responses should the nurse make?
A. "As the healthcare surrogate, your partner can make the decision."
B. "I will need to discuss this with the healthcare team before proceeding."
C. "It's important to consider what the client would have wanted."
D. "Family opinions are important, but the surrogate's decision is what matters."
Answer: A. "As the healthcare surrogate, your partner can make the decision."
A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse
distracts the client and quickly administers the injection. This illustrates which of the
following?
A. Battery.
B. Assault.
C. Negligence.
D. Informed consent.
Answer: A. Battery.

A nurse is caring for a client who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted in regard to this client’s care? (Select all
that apply.)
A. Nutritional therapist.
B. Mental health counselor.
C. Case manager.
D. Physician.
Answer: A. Nutritional therapist,
B. Mental health counselor,
C. Case manager.
A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates understanding of isolation
guidelines?
A. "I will have a client who is on airborne precautions wear a mask when out of her room."
B. "I will ensure that the client stays in her room at all times."
C. "I will use gloves and gowns whenever I enter the client's room."
D. "I will place the client in a private room with a door that remains open."
Answer: A. "I will have a client who is on airborne precautions wear a mask when out of her
room."
Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following
is appropriate to include in the cost-containment plan?
A. Use clean gloves rather than sterile gloves for colostomy care.
B. Limit the use of disposable supplies during procedures.
C. Schedule more frequent assessments to catch complications early.
D. Increase the number of staff members on the unit during peak hours.
Answer: A. Use clean gloves rather than sterile gloves for colostomy care.
A nurse is caring for a client who has cancer. The client’s adult child asks the nurse for
information about the client’s treatment plan. Which of the following responses should the
nurse make?
A. "I cannot provide this information to you without your mother’s consent."
B. "Your mother has already given me permission to share her treatment plan."

C. "I can give you general information about cancer treatments, but not specifics about your
mother’s plan."
D. "Why don’t you ask your mother directly about her treatment?"
Answer: A. "I cannot provide this information to you without your mother’s consent."
A nurse in the emergency department is performing triage for a group of clients who were in
a train crash. Which of the following clients should the nurse tag as emergent?
A. A client who has a deep partial-thickness burn on the lower extremities.
B. A client who has an open fracture of the femur.
C. A client who has a head injury with altered level of consciousness.
D. A client who has a periorbital ecchymosis.
Answer: C. A client who has a head injury with altered level of consciousness.
A nurse is caring for a client who has a tumor. The provider recommends surgery. The client
refuses, but the client’s partner wants the surgery performed. Which of the following is the
deciding factor in determining if the surgery will be done?
A. Whether the client understands their risk of refusing the procedure.
B. Whether the client has signed an informed consent form.
C. Whether the partner has legal authority to make medical decisions.
D. Whether the client’s condition is life-threatening.
Answer: B. Whether the client has signed an informed consent form.
A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following
actions should the nurse take?
A. Report the infection to the local health department.
B. Provide information about the infection to the client.
C. Refer the client to a specialist for further treatment.
D. Schedule a follow-up appointment in one month.
Answer: A. Report the infection to the local health department.
A nurse manager is receiving report and is faced with the following situations that require
intervention. Which of the following should the nurse manager address first?
A. A nurse on the previous shift wrote an incident report about a medication error.
B. Two staff members have called to say they will be absent.

C. Transport assistance is unavailable to take a client to occupational therapy.
D. The emergency department nurse is waiting to give report on a new admission.
Answer: D. The emergency department nurse is waiting to give report on a new admission.
A charge nurse notices that two staff nurses are not taking meal breaks during their regular 8hour shifts. Which of the following actions should the nurse take first?
A. Determine the reasons the nurses are not taking scheduled breaks.
B. Remind the nurses about the importance of taking breaks.
C. Schedule mandatory break times for the nurses.
D. Report the nurses to the nurse manager for not following policy.
Answer: A. Determine the reasons the nurses are not taking scheduled breaks.
A nurse is receiving a verbal prescription from the provider for a client who is having
increased pain. The nurse should transcribe which of the following prescriptions in the
client’s medical records?
A. "Morphine sulfate 10 mg IV q 4 hr for pain."
B. "Morphine sulfate 4 mg IV q 4 hr for pain."
C. "Morphine sulfate 10.0 mg IV q 4 hr for pain."
D. "Morphine sulfate 4 mg IV q 2 hr for pain."
Answer: A. "Morphine sulfate 10 mg IV q 4 hr for pain."
A nurse working in the emergency department is assessing several clients. Which of the
following clients is the highest priority?
A. A client who reports shortness of breath and left neck and shoulder pain.
B. A client with a sprained ankle and mild swelling.
C. A client with a headache and a history of migraines.
D. A client with a fever and a rash.
Answer: A. A client who reports shortness of breath and left neck and shoulder pain.
A nurse is caring for a client who has a prescription for transcutaneous electrical nerve
stimulation (TENS). Which of the following members of the interdisciplinary team should
the nurse contact for assistance?
A. Physical therapist.
B. Occupational therapist.

C. Pain management specialist.
D. Nurse practitioner.
Answer: A. Physical therapist.
A nurse is teaching a newly licensed nurse about implementing droplet precautions for a
client who has influenza. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
A. "I will wear a surgical mask within 3 feet of the client."
B. "I will wear a gown and gloves when entering the room."
C. "I can remove the mask once I leave the room."
D. "I will place the client in a private room with negative pressure."
Answer: A. "I will wear a surgical mask within 3 feet of the client."
A nurse is caring for four clients. Which of the following clients should the nurse assess first?
A. A client who has Alzheimer's disease and bacterial pneumonia and is in a new onset of
restlessness.
B. A client with stable vital signs who is post-operative day one.
C. A client with diabetes who has a blood glucose level of 150 mg/dL.
D. A client with a history of anxiety who reports feeling calm today.
Answer: A. A client who has Alzheimer's disease and bacterial pneumonia and is in a new
onset of restlessness.
A nurse is developing a discharge plan for a client who is post-operative and will require a
wheelchair in the home. The nurse should place a referral to which of the following resources
to obtain the clients prescription?
A. Home health
B. Physical therapy
C. Occupational therapy
D. Social services
Answer: D. Social services
A nurse is working on a quality improvement team that is assessing an increase in client falls
at a facility. After problem identification, which of the following actions should the nurse
plan to take first as part of the quality improvement process?

A. Identify clients who are at risk for falls.
B. Develop a fall prevention policy.
C. Analyze the data on past falls.
D. Implement staff training on fall prevention.
Answer: A. Identify clients who are at risk for falls.
A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to
the facility. Which of the following triage tag colors should the nurse instruct the group to
apply to a client who has full thickness burns on 72% of his body?
A. Red
B. Yellow
C. Green
D. Black
Answer: D. Black
A nurse has just completed assessment charting on an electronic medical record for an
assigned client. An assistive personnel who just measured the client's vital signs asks to chart
them while the nurse is still logged in. Which of the following actions should the nurse take?
A. Log out so the assistive personnel can log in to document the vital signs.
B. Allow the assistive personnel to chart the vital signs under the nurse’s login.
C. Ask the assistive personnel to wait until the nurse has finished charting.
D. Document the vital signs for the assistive personnel.
Answer: A. Log out so the assistive personnel can log in to document the vital signs.
A nurse is caring for a client who has been admitted and diagnosed with type 1 diabetes
mellitus. The client tells the nurse she has decided to go home. Which of the following
actions should the nurse take?
A. Have the client sign the Against Medical Advice form.
B. Inform the client about the risks of leaving the hospital.
C. Call the healthcare provider to discuss the client's decision.
D. Encourage the client to stay for further evaluation.
Answer: A. Have the client sign the Against Medical Advice form.

A nurse in an ambulatory care setting is orienting a newly licensed nurse who is preparing to
return a call to a client. The nurse should explain that which of the following is an objective
of telehealth?
A. Assessing client needs.
B. Providing medication reconciliation.
C. Developing client treatment protocols.
D. Establishing communication between providers.
Answer: D. Establishing communication between providers.
A nurse is delegating care for a group of clients. Which of the following clients should the
nurse assign to a licensed practical nurse (LPN)?
A. A client who is scheduled for an endoscopy later today and requires an enema.
B. A client who has had a myocardial infarction and will be transferring to a unit from the
PCC.
C. A newly admitted client who has diabetes mellitus and requires initial teaching on selfadministration of insulin.
D. A newly admitted client who has sickle cell anemia and requires the development of an
initial plan of care.
Answer: A. A client who is scheduled for an endoscopy later today and requires an enema.
A nurse in the emergency department admits a client who has been exposed to cutaneous
anthrax. Which of the following actions should the nurse take?
A. Prepare to administer antibiotics to the client.
B. Place the client in isolation.
C. Conduct a thorough respiratory assessment.
D. Provide the client with discharge instructions.
Answer: A. Prepare to administer antibiotics to the client.
A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of
the following information should the nurse include in the change of shift report?
A. The time the client received his last dose of pain medication.
B. The client’s favorite activities in rehabilitation.
C. The names of the client’s family members.
D. The client’s personal preferences for meals.

Answer: A. The time the client received his last dose of pain medication.
A nurse on a medical-surgical unit is evaluating an assistive personnel's use of infection
control precautions. Which of the following actions by the assistive personnel indicates
correct use of precautions?
A. The AP removes her gloves before leaving the room of a client who has MRSA.
B. The AP washes hands before entering the client’s room.
C. The AP wears a mask when providing care to the client.
D. The AP uses a gown when assisting the client.
Answer: A. The AP removes her gloves before leaving the room of a client who has MRSA.
A nurse on a med-surg unit is caring for a client who asks about advance directives and states
that he wants to appoint a healthcare proxy. Which of the following responses should the
nurse make?
A. “A healthcare proxy can make decisions for you when you are unable to do so.”
B. “You need to complete a form to appoint your healthcare proxy.”
C. “Your family members can make decisions for you in the hospital.”
D. “It’s not necessary to appoint a healthcare proxy if you have a living will.”
Answer: A. “A healthcare proxy can make decisions for you when you are unable to do so.”
A nurse is teaching a newly licensed nurse about client confidentiality. The nurse should
include that which of the following examples represents a violation of client confidentiality?
A. Informing housekeeping staff that the client is in the dialysis unit.
B. Discussing the client’s treatment plan with the healthcare team during rounds.
C. Documenting the client’s care in the electronic health record.
D. Sharing the client’s diagnosis with family members who are not involved in care.
Answer: A. Informing housekeeping staff that the client is in the dialysis unit.
A nurse is providing change-of-shift report for an oncoming nurse. Which of the following
information should the nurse include in the report?
A. “The client is currently in the radiology department for a chest x-ray.”
B. “The client had a good night and was stable throughout the shift.”
C. “The client prefers to have their meals at 12 PM.”
D. “The client’s family visited yesterday and will return later.”

Answer: A. “The client is currently in the radiology department for a chest x-ray.”
A nurse is preparing a teaching session with a client who speaks a different language than the
nurse. Which of the following interventions should the nurse plan to take?
A. Provide an interpreter when obtaining consent from the client.
B. Use family members to translate for the client.
C. Provide written materials in the client’s language.
D. Speak slowly and use simple words to communicate.
Answer: A. Provide an interpreter when obtaining consent from the client.
A charge nurse witnessed an assistive personnel failing to follow facility protocol when
discarding contaminated linens. Which of the following actions should the nurse take first?
A. Discuss the issue with the AP.
B. Report the incident to the nurse manager.
C. Document the observation in the AP's performance record.
D. Provide a refresher training session on infection control.
Answer: A. Discuss the issue with the AP.
A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that
which of the following clients is the highest priority?
A. A client who has peripheral vascular disease and has an absent pedal pulse in their right
foot.
B. A client who has a new diagnosis of diabetes and is receiving education.
C. A client who is post-operative and has mild pain controlled by medication.
D. A client with a history of hypertension who is due for their medication.
Answer: A. A client who has peripheral vascular disease and has an absent pedal pulse in
their right foot.
A nurse in the emergency department is preparing to care for a client who arrived via
ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following
actions should the nurse take?
A. Have the client sign a consent for treatment
B. Notify risk management before initiating treatment
C. Proceed with treatment without obtaining written consent (Implied Consent)

D. Contact the client’s next of kin to obtain consent for treatment
Answer: D. Contact the client’s next of kin to obtain consent for treatment
A client is brought to the emergency department following a motor-vehicle crash. Drug use is
suspected in the crash, and avoided urine specimen is ordered. The client repeatedly refuses
to provide the specimen. Which of the following is the appropriate action by the nurse?
A. Tell the client that a catheter will be inserted.
B. Document the client’s refusal in the chart
C. Assess the client for urinary retention.
D. Obtain a provider’s prescription for a blood alcohol level.
Answer: B. Document the client’s refusal in the chart
A nurse is planning care for a group of clients and can delegate care to a licensed practical
nurse(LPN) and an assistive personnel. Which of the following tasks should the nurse assign
to the LPN?
A. Reinforcing teaching with a client who is learning to self-administer insulin
B. Ambulating a client who is scheduled for discharge later in the day
C. Administering morphine IV bolus toa client who is hr postoperative
D. Admitting a new client who has chronic back pain to the unit
Answer: A. Reinforcing teaching with a client who is learning to self-administer insulin
A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After
the nurse administers the prescribed opioid and benzodiazepine, the client becomes
somnolent and difficult to arouse. Which of the following actions should the nurse take?
A. With hold the benzodiazepine but continue the opioid.
B. Contact the provider a boutre placing the opioid with a n NSAID.
C. Administer the benzodiazepine but with hold the opioid.
D. Continue the medication dosages that relieve the client’s pain.
Answer: A. Reinforcing teaching with a client who is learning to self-administer insulin
A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold
Wedding band. Which of the following is an appropriate procedure for taking care of this
client’s ring?
A. Place the client’s ring in the facility safe.

B. Tape the ring securely to the client’s finger.
C. Place the ring in the bag with the client’s clothing.
D. Agree to keep the ring for the client until after surgery.
Answer: A. Place the client’s ring in the facility safe.
A nurse in an urgent care clinic is admitting a client who has been exposed toa liquid
chemical in an industrial setting. Which of the following actions should the nurse take first?
A. Don personal protective equipment
B. Irrigate the exposed area with water
C. Remove the client’s clothing
D. Report the incident to OSHA
Answer: A. Don personal protective equipment
A nurse manager is making staffing assignments for the maternal newborn unit. Which of
The following clients should he nurse manager assign to a float nurse from the medicalsurgical unit?
A. A client who is post term and is receiving goxytocin for labor induction
B. A client who gave birth to her first child and requires instruction on breastfeeding
techniques
C. A client who is 2 days post-operative following a caesarean birth and is having difficulty
ambulating
D. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion
Answer: C. A client who is 2 days post-operative following a caesarean birth and is having
difficulty ambulating
A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a
client. Which of the following actions should the nurse take?
A. Treat the client’s injuries within30 min
B. Provide treatment for life-threatening injuries
C. Provide treatment for minor injuries
D. Allow the client to die without further intervention
Answer: B. Provide treatment for life-threatening injuries

To receive a conflict between staff members regarding potential changes in policy, a nurse
manager decides to implement the changes she prefers regardless of the feelings of those who
oppose those changes. Which of the following conflict-resolution strategies is the nurse
manager using?
A. Compromising
B. Cooperating
C. Competing
D. Collaborating
Answer: C. Competing
A nurse on a medical-surgical unit is caring for four clients. Which of the following findings
is the highest priority?
A. A client who had a cardiac catheterization whose capillary refill in the great toe is 4
seconds.
B. A client who has COPD and has an oxygen saturation of 90%
C. A client who had a cholecystectomy 6 hr ago and is requesting pain medication
D. A client whose TPN was discontinued 4 hr ago and is requesting clear liquids
Answer: A. A client who had a cardiac catheterization whose capillary refill in the great toe
is 4 seconds.
ATI RN LEADERSHIP PROCTORED EXAM 2019 VERSION 3
A nurse is assessing a school-age child who has heart failure and is taking furosemide.
Which of the following findings should the nurse identify as an indication that the medication
is effective?
A. An increase in venous pressure
B. A decrease in peripheral edema
C. a decrease in cardiac output
D. an increase in potassium levels
Answer: B. A decrease in peripheral edema
A nurse is assessing an infant who has acute otitis media. Which of the following findings
should the nurse expect (select all that apply)
A. Increased appetite

B. Enlarged subclavian lymph node
C. Crying
D. Restlessness.
E. fever
Answer: B. Enlarged subclavian lymph node
C. Crying
D. Restlessness.
E. fever
A nurse is providing teaching to the parents of an infant who is to undergo pilocarpine
iontophoresis testing for cystic fibrosis. Which of the following statements should the nurse
include in the teaching?
A. We will measure the amount of protein in your baby's urine over a 24-hour period.
B. The test will measure the amount of water in your baby’s sweat.
C. A nurse will insert an IV prior to the test.
D. Your baby will need to fast for 8 hours prior to the test.
Answer: B. The test will measure the amount of water in your baby’s sweat.
A nurse in an urgent care clinic is prioritizing care for children. Which of the following
children should the nurse assess first?
A. A toddler who has nephrotic syndrome and facial edema
B. A preschool-age child who has a muffled voice and no spontaneous cough
C. A preschool-age child who has diabetes mellitus and a blood glucose of 200 mg/dL
D. An adolescent who has Crohn's disease and recent weight loss of 5 kg (11 lb)
Answer: B. A preschool-age child who has a muffled voice and no spontaneous cough.
A nurse is providing teaching to the parents of a toddler who is to undergo a sweat chloride
test. Which of the following statements should the nurse include?
A. The purpose of the test is to determine if your child has Crohn's disease.
B. The technician will use a device to produce an electrical current during the test.
C. During the test, your child will be in a room that is cold.
D. If your child sweats, it will be collected over 24 hours.
Answer: B. The technician will use a device to produce an electrical current during the test.

A nurse in the emergency department is caring for an adolescent who is requesting testing for
STI. Which of the following action is appropriate for the nurse to take?
A. Request verbal consent from the social worker
B. Contact the client's parents to obtain phone consent
C. Postpone the testing until the client's parents are present.
D. Obtain written consent from the client
Answer: D. Obtain written consent from the client
A nurse in the emergency department is assessing the toddler who has hyperpyrexia severe
dyspnea and drooling which of the following actions should the nurse take first?
A. Obtain a blood culture from the toddler
B. Administer antibiotics to the toddler
C. Insert an IV catheter for the toddler
D. Prepare the toddler for nasotracheal intubation
Answer: D. Prepare the toddler for nasotracheal intubation
A nurse is providing teaching to a 10 year old child with scheduled for an arterial cardiac
catheterization. Which of the following information should the nurse include in the teaching?
A. You will have your dressing removed 12 hours after the procedure.
B. You will need to keep your legs straight for 8 hours following the procedure.
C. You will be on a clear liquid diet for 24 hours following the procedure.
D. You will be on bed rest for 2 days after the procedure.
Answer: B. You will need to keep your legs straight for 8 hours following the procedure.
A nurse is caring for a preschooler who is post-operative following a tonsillectomy. The child
is now ready to resume oral intake which of the following dietary choices should the nurse
offer the child?
A. sugar-free Cherry gelatine
B. vanilla ice cream
C. chocolate milk
D. lime flavored ice pop
Answer: D. lime flavored ice pop

A nurse is caring for an infant who has Patent ductus arteriosus. The nurse should identify
that the defect is a switch of the following locations of the heart. (you Will find hot spots to
select in the artwork below. Select only the hot spot that corresponds to Your answer)
A. Aorta
B. Pulmonary artery
C. Left atrium
D. Right ventricle
Answer: B. Pulmonary artery
A nurse is caring for a 10 month old child was brought to the emergency department by his
parents following a head injury. Which of the following actions should the nurse take first?
A. Inspect for fluid leaking from the ears
B. Assess respiratory status
C. check pupil reactions
D. examine the scalp for lacerations
Answer: B. Assess respiratory status
A charge nurse is planning care for an infant who has failure to thrive. Which of the
following actions should the nurse include in the plan of care?
A. Assign consistent nursing staff care for the infant.
B. Keep the infant in a visually stimulating environment.
C. Use half-strength formula when feeding the infant.
D. Give the infant fruit juice between feedings.
Answer: C. Use half-strength formula when feeding the infant.
A nurse is providing teaching about home care to the parent of a child who has scabies.
Which of the following instruction should the nurse include in the teaching?
A. Wash your client's hair with shampoo containing Ketoconazole.
B. Soak combs and brushes in boiling water for 10 minutes.
C. Apply petroleum jelly to the affected areas.
D. Treat everyone who came into close contact with a child.
Answer: B. Soak combs and brushes in boiling water for 10 minutes.

A nurse is caring for a preschooler who refuses to take a start dose of oral diphenhydramine.
Which of the following statements should the nurse make?
A. The medication isn't bad; it tastes like candy.
B. Let me know when you want to take the medication.
C. The medication will treat your hypersensitivity reaction.
D. Sometimes, when a child has to take medication, they feel sad.
Answer: A. The medication isn't bad; it tastes like candy.
A nurse is teaching the parent of a school-age child about bicycle safety. Which of the
following instructions should the nurse include in the teaching?
A. Your child should walk the bicycle through intersections.
B. Your child's feet should be three to six inches off the ground when seated on the bicycle.
C. You should try to keep the bicycle at least three feet from the curb while riding in the
street.
D. Your child should ride the bicycle against the flow of traffic.
Answer: A. Your child should walk the bicycle through intersections.
A nurse is caring for a school-age child following the application of a cast to a Fractured right
tibia. Which of the following actions should the nurse take first?
A. Teach the child about cast care
B. Pad the edges of the cast
C. administer pain medication.
D. Elevate the child's leg
Answer: D. Elevate the child's leg
A nurse is preparing a school-age child for an invasive procedure. Which of the following
actions should the nurse plan to take?
A. Plan for a 30-minute teaching session about the procedure.
B. Use vague language to describe the procedure.
C. Explain the procedure to the child when they are in the playroom.
D. Demonstrate deep breathing and counting.
Answer: A. Plan for a 30-minute teaching session about the procedure.
Exercises 20.

A nurse is preparing to collect a urine specimen from a female infant using a urine collection
bag. Which of the following actions should the nurse take?
A. Apply lidocaine gel to the perineum before attaching the bag.
B. Position the opening of the bag over the urethra and the anus.
C. Stretch the perineum taut when applying the bag.
D. Place a snug-fitting diaper over the drainage bag.
Answer: C. Stretch the perineum taut when applying the bag.
A nurse is planning care for a toddler who has developed oral ulcers in response to
chemotherapy. Which of the following actions should the nurse include in the plan of care?
A. Schedule routine oral care every 8 hours.
B. Cleanse the gums with saline-soaked gauze.
C. Moisten the mucosa with lemon glycerine swabs.
D. Administer oral viscous lidocaine.
Answer: B. Cleanse the gums with saline-soaked gauze.
A nurse is providing discharge teaching to the parents of an infant who is at risk for sudden
infant death syndrome (SIDS). Which of the following statements by the parent indicates an
understanding of the teaching?
A. I will have my baby sleep next to me in the bed during the night.
B. I will move my baby’s stuffed animal to the corner of her crib while she sleeps.
C. I will dress my baby in lightweight clothing to sleep.
D. I will lay my baby on her side to sleep for her naps.
Answer: C. I will dress my baby in lightweight clothing to sleep.
A nurse is monitoring an infant who is receiving opioids for pain. Which of the following
findings should indicate to the nurse that the medication is having a therapeutic effect?
A. Increased blood pressure
B. Limb withdrawal
C. relaxed facial expression
D. bradycardia
Answer: C. relaxed facial expression

A nurse is caring for a three-month-old infant who has cleft of the soft palate. Which of the
following actions should the nurse take?
A. Discontinue feeding if the client's eyes become watery.
B. Postpone burping the infant until after completing each feeding.
C. Elevate the infant’s head to a 10-degree angle during feedings
D. Feed the infant 177.4 ml (6 oz) of formula 3 times a day.
Answer: A. Discontinue feeding if the client's eyes become watery.
A nurse is caring for a child who has hyponatremia. Which of the following findings should
the nurse expect?
A. Tetany
B. weight gain
C. Elevated heart rate
D. excessive diaphoresis
Answer: A. Tetany
A nurse is preparing to administer an enteral feeding to an adolescent who has an NG tube.
Which of the following actions should the nurse take first?
A. Set the administration rate on the feeding pump
B. flush the tube with water
C. check the pH of the gastric secretion
D. attach the feeding bag tubing to the end of the NG Tube
Answer: A. Tetany
A nurse is caring for an adolescent who is 1 hour post-operative following an appendectomy.
Which of the following findings should the nurse report to the provider?
A. Heart rate 63/minute
B. muscle rigidity
C. temperature 36.4 Celsius (97.5 Fahrenheit)
D. abdominal pain
Answer: B. muscle rigidity

A nurse in a provider's office is preparing to administer immunization to a12 year old client
during a well-child visit. Which of the following immunization should the nurse plan to
administer?
A. Diphtheria, tetanus and pertussis (D-Tap)
B. human papillomavirus (HPV)
C. Varicella
D. hepatitis A
Answer: A. Diphtheria, tetanus and pertussis (D-Tap)
Nurse is planning care for an 8 month old infant who has heart failure. Which of the
following actions should the nurse include in the plan of care?
A. Repeat digoxin dosage is the infant vomit within 1 hour of administration
B. Place infant in a prone position
C. administer cool, humidified oxygen via nasal cannula
D. provide less frequent, higher volume feeding
Answer: C. administer cool, humidified oxygen via nasal cannula
A nurse is planning care for a school-age child who is admitted from the emergency
department 12 hours ago. Which of the following interventions should the nurse include to
promote adequate sleep for the child?
A. Provide the child with video games prior to bedtime to reduce stress
B. Allow the child to adjust their bed time to promote autonomy
C. leave the lights on in the child's room to promote safety
D. follow the child home sleep routine to reduce anxiety
Answer: C. administer cool, humidified oxygen via nasal cannula
A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12 month old
infant. Which of the following actions should the nurse plan to take?
A. cover the insertion site with an opaque dressing
B. use a 24 gauge catheter to start the IV
C. start the IVon the infant’s foot
D. change the IV site every 3 days
Answer: B. use a 24 gauge catheter to start the IV

A nurse in a paediatric clinic is providing teaching to the guardian of an infant who has a new
prescription for digoxin. Which of the following manifestations should the nurse include as
an indication of digoxin toxicity?
A. Diaphoresis
B. Polyuria
C. Bradycardia
D. jaundice
Answer: C. Bradycardia
A nurse is preparing to administer amoxicillin 80 mg/kg/day divided into two doses daily to a
2-year-old client who weighs 10 kg (22 lb). Available is amoxicillin suspension 400 mg/5
mL. how many mL of amoxicillin should the nurse administer per dose? (Round the answer
to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
A. 10ml
B. 50ml
C. 5 ml
D. 90 mL
Answer: A. 10ml
A nurse is reviewing the laboratory results of a child was recently admitted or suspected
rheumatic fever. The nurse should identify that which of the following laboratory tests can
contribute to confirm this diagnosis (select all that apply)
A. partial thromboplastin time (PTT)
B. erythrocyte is sedimentation rate (ESR)
C. blood urea nitrogen (BUN)
D. C-reactive protein (CRP)
E. Anti streptolysin O(ASO) titer
Answer: B. erythrocyte is sedimentation rate (ESR)
D. C-reactive protein (CRP)
E. Anti streptolysin O(ASO) titer
A nurse is teaching a group of female adolescents about healthy eating. Which of the
following instructions should the nurse include in the teaching?
A. Increase the amount of your dietary iron intake.

B. limit your sodium intake to 3000 mg per day
C. consumer 1,500 to 1700 calories per day
D. decrease your vitamin D intake once you start to menstruate
Answer: A. Increase the amount of your dietary iron intake.
A nurse is caring for an infant who receives intermittent enteral feeding through a
gastrostomy tube. Which of the following actions should the nurse take when administering a
feeding? Select all that apply
A. Offer the infant a pacifier during readings.
B. Heat the formula to 39°C (102 degrees Fahrenheit) prior to administration.
C. Check for residual volume by aspirating stomach contents.
D. Instill the formula over a period of 30 to 45 minutes.
Answer: A. Offer the infant a pacifier during readings.
C. Check for residual volume by aspirating stomach contents.
A nurse is planning care for a child who has osteomyelitis. Which of the following
interventions should the nurse include in the plan of care?
A. Encourage frequent physical activity to increase bone mass
B. maintain patent intravenous catheter
C. initiate contact precaution for the child
D. provide a high calorie low protein diet
Answer: C. initiate contact precaution for the child
A nurse is providing teaching to the guardian of a school-age child who has sickle cell disease
about management of the illness. Which of the following instructions should the nurse
include?
A. Apply cold compress to painful areas
B. but I shall wear a surgical mask to school
C. encourage physical activity as tolerated
D. offer fluids of bedtime
Answer: C. initiate contact precaution for the child
A nurse is assessing a 5 month old infant. Which of the following findings should the nurse
report to the provider?

A. Unable to hold a bottle
B. exhibits head lag when pulled a sitting position
C. absent grasp reflex
D. unable to roll from back to abdomen
Answer: D. unable to roll from back to abdomen
A nurse is caring for a five-year-old child following a tonsillectomy and adenoidectomy.
Which of the following findings should the nurse identify as an indication of haemorrhage?
A. Flushing of the face
B. continuous swallowing
C. blood pressure 99/56 mm hg
D. heart rate 54/ minutes
Answer: B. continuous swallowing
A nurse is discussing coping mechanisms with a parent of a three-month- old infant which of
the following therapeutic questions should the nurse ask the parent?
A. What do you do when your infant is fussy?
B. Are you willing to take new parenting classes?
C. Does parenting cause you stress?
D. Is it overwhelming when your infant is having a bad day?
Answer: D. Is it overwhelming when your infant is having a bad day?
A nurse is providing teaching about the effects of sun exposure to a parent of a toddler. which
of the following responses by the parent indicates an understanding of the teaching?
A. my child should wear a wide-brimmed hat
B. my child should remain under a beach umbrella during morning hours
C. I should apply 10 SPF sunscreen to my child's entire Body
D. I should dress my child in loose, active clothing.
Answer: D. I should dress my child in loose, active clothing.
A nurse is evaluating a 6 year old child who has cystic fibrosis and has been receiving chest
physiotherapy treatment. The nurse should identify which of the following findings as an
indication of the therapy has been effective?
A. Increased urine output

B. increase expectoration
C. reduced pain
D. increased heart rate
Answer: B. increase expectoration
A nurse is planning care for a six-month-old infant who has bacterial meningitis. Which of
the following interventions should the nurse include in the plan of care?
A. Place the infant in a semi-private room.
B. keep the television on in the room to provide background noise
C. Pad the side rails of the crib
D. provide for you can range of motion to the neck and shoulders
Answer: A. Place the infant in a semi-private room.
A nurse is reviewing the medical record of a child with cystic fibrosis which of the following
should the nurse report to the provider? Click on the exhibit button for additional information
about the client.
A. heart rate
B. HbA1c
C. oxygen saturation
D. WBC 48.
Answer: C. oxygen saturation
A nurse is assessing an infant who has severe dehydration due to gastroenteritis which of the
following findings should the nurse expect?
A. Increased respiratory irate
B. capillary refill of 2 seconds
C. Hypertension
D. increased urine output
Answer: A. Increased respiratory irate
A nurse is assessing an infant who has intussusception. Which of the following findings
should the nurse expect?
A. sausage-shaped abdominal Mass
B. board like abdomen

C. Constipation
D. increased urinary output
Answer: A. sausage-shaped abdominal Mass
A nurse is caring for a 14 year old adolescent who has a cast on the right arm and swelling of
their right hand. The nurse elevates The Adolescents affected extremity. The nurse should
identify that which of the following findings is an indication that the intervention has been
effective?
A. The Adolescent reports of the cast feels tight
B. The Adolescents hands feel cool to touch
C. the Adolescent is able to move their fingers freely
D. the Adolescent reports feeling tingling in their arms
Answer: C. the Adolescent is able to move their fingers freely
A nurse in a provider's office is assessing the vital signs of a two-year- old child at a wellchild visit. Which of the following findings should the nurse report to the provider?
A. Respiratory rate 26/min
B. pulse rate 98/minutes
C. temperature 37.2 Celsius (99 Fahrenheit)
D. blood pressure 118/74 mm hg
Answer: D. blood pressure 118/74 mm hg
A nurse is preparing to administer a prescribed medication to a toddler whose parent is
nearby. Which of the following actions should the nurse take to identify the toddler?
A. Check the toddler's room number against their ID band.
B. Check the toddler's ID band against the medical record.
C. Ask the parent to confirm the toddler's identity.
D. Ask another nurse to confirm the toddler's identity.
Answer: B. Check the toddler's ID band against the medical record.
A nurse is teaching home care to the parents of a preschool-age child who has heart failure.
Which of the following information should the nurse include in the teaching?
A. Weight the child once each month.
B. withhold digoxin of the child's pulse is greater than 100/minutes

C. provide for periods of rest
D. increase the child's oxygen flow rate until the child no longer has cyanosis
Answer: C. provide for periods of rest
A nurse in the PACU is caring for a school-age child immediately following a tonsillectomy.
Which of the following actions should the nurse take?
A. Place the child in a side-lying position.
B. offer the child ice cream when alert
C. instruct a child to drink fluids through a straw
D. encourage the child to deep breath and cough
Answer: A. Place the child in a side-lying position.
A nurse is reviewing the medical record of a 15 month old child who is scheduled to receive
measles, mumps, rubella1. Which of the following findings Should the nurse identify as a
contradiction for receiving the vaccine?
A. Allergy to neomycin
B. upper respiratory infection 2 days ago
C. temperature of 37.2 (99 Fahrenheit)
D. family history of seizures
Answer: A. Allergy to neomycin
A nurse is assessing a school-age child cranial nerve function. Which of the following actions
should the nurse ask the child to take when assessing the accessory nerve?
A. Move their tongue in all directions
B. follow a light in the six cardinal position
C. shrug their shoulders against mild pressure
D. show their teeth while smiling
Answer: A. Allergy to neomycin
A nurse is performing a cranial nerve assessment on a school-age child. Which of the
following findings indicates proper function of the child trigeminal nerve?
A. The child montanes balance when standing with eyes closed
B. the child correctly identify specific scent
C. The child has asymmetrical jaw strength when biting down.

D. the child exhibits a gag reflex when stimulated with a tongue blade
Answer: C. The child has asymmetrical jaw strength when biting down.
A nurse is providing support to a family whose infant died from sudden infant death
syndrome (Sid's) which of the following actions should the nurse take?
A. Discourage the parents from allowing siblings to view the body
B. avoid discussing details of the attempt to revive the infant
C. provide a follow-up phone call one week following the infant's death
D. acknowledge the family members feelings of guilt
Answer: D. acknowledge the family members feelings of guilt
A nurse in the emergency department is caring for a child who has a temperature of 39.1
degrees C is (102.4 Fahrenheit) and suspect the diagnosis of bacterial meningitis. Which of
the following actions should the nurse take first? Tell me more
A. prepare the child for a lumbar puncture
B. dim the lights in the child's room
C. administering an antipyretic to the child
D. Implement droplet precautions for the child
Answer: D. Implement droplet precautions for the child
A nurse is caring for an infant who has rotavirus. Which of the following findings indicates
that the infant is moderately dehydrated?
A. capillary refill 1 Seconds
B. weight loss 7% lower
C. Respiratory rate 28/ minute
D. bradycardia
Answer: D. Implement droplet precautions for the child
A nurse is providing teaching to the guardian of a school-age child who has seizure disorder.
Which of the following factors should the nurse include as a common trigger that increases
the risk of seizure?
A. Prolonged headache
B. decrease temperature
C. lack of sleep

D. exposure to second-hand smoke
Answer: A. Prolonged headache
A nurse is reviewing the laboratory results of a preschooler who has gastroenteritis and notes
the clients potassium level is 3.2 meqL which of the following assessment findings should the
nurse expect?
A. Hypertension
B. Hyporeflexia
C. hyperactive bowel sounds
D. Oliguria
Answer: A. Prolonged headache
A nurse is planning care for an adolescent who has sickle cell anemia. Which of the following
immunizations should the nurse include in the plan?
A. Respiratory sync functional virus (RSV to call)
B. Rotavirus
C. measles, mumps, and rubella (MMR)
D. pneumococcal conjugate (pcv13)
Answer: A. Prolonged headache
A nurse is planning care for a child who has varicella. Which of the following interventions
should the nurse plan to include?
A. Initiate Airborne precaution
B. assess the oral cavity for koplik spots
C. administer aspirin for fever
D. provide the child with a warm blanket
Answer: A. Initiate Airborne precaution
A nurse is planning care for a school-age child who has a new diagnosis of Legg calve
Perthes disease. Which of the following interventions should the nurse include in the plan of
care?
A. instruct a child to perform weight bearing exercises
B. explain to the child that the disease will last 3 to 6 months
C. encourage the guardian to keep their child home from school for one month

D. Administer ibuprofen to the child for discomfort.
Answer: D. Administer ibuprofen to the child for discomfort.
A nurse is caring for a two-year-old child who has cystic fibrosis and is being discharged
from the hospital. The nurse should ensure that which of the following pieces of equipment is
available for the child's home?
A. steam vaporizer
B. suction machine
C. continuous positive airway pressure machine
D. high frequency chest compression vest
Answer: D. high frequency chest compression vest
A nurse is providing teaching for the parent of a child who has measles. Which of the
following information should the nurse include?
A. Bathe the child using tepid water.
B. remove loose crust from the lesions
C. give the child aspirin for a fever
D. withhold live vaccines for 3 months
Answer: A. Bathe the child using tepid water.
A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings should
the nurse expect?
A. Steatorrhea
B. Rhinorrhea
C. weight gain
D. visible peristalsis
Answer: A. Steatorrhea
A nurse is planning to administer diphenhydramine 1.25 mg/kg IV to a school-age child who
weighs 55 lb. Available is diphenhydramine 50 mg / ml. How many ml should the nurse
administer. Round the answer to the nearest tenth. Use leading zero that applies. Do not use a
trailing zero.
A. 0.2 ml
B. 0.6 ml

C. 0.8 ml
D. 1.0 ml
Answer: B. 0.6 ml

ATI RN LEADERSHIP PROCTORED EXAM 2019 VERSION 2
written by Nurse Nancy
ATI Leadership Proctored Exam
A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change
in the wound care procedure. Which of the following findings indicate wound healing?
A. Erythema on the skin surrounding a client's wound
B. Deep red color on the center of the client's wound
C. Inflammation noted on the tissue edges of a client's wound
D. Increase in serosanguineous exudate from the client's wound
Answer: B. Deep red color on the center of the client's wound
A nurse received change of shift report at 0700 for four clients. Which of the following
actions should the nurse perform first?
A. Obtain a breakfast tray for a client who received a morning dose of insulin as part
B. Administer pain medication toa client who has rheumatoid arthritis and received the last
dose at 0400
C. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
D. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours.
Answer: A. Obtain a breakfast tray for a client who received a morning dose of insulin as
part
A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following
clients should the nurse assign to the newly licensed nurse?
A. A client who has multiple sclerosis and ataxia
B. A client who has a brain tumor and is admitted for chemotherapy
C. A client who has Guillain-Barre syndrome and a tracheostomy
D. A client who sustained a concussion and is being monitored for complication

Answer: A. Obtain a breakfast tray for a client who received a morning dose of insulin as
part
A nurse is providing teaching to a client about advance directives. Which of the following
statements by the client indicates an understanding of the teaching?
A. “Once I sign my living will, a family member must co-sign it.”
B. “I will wait until I have serious health problems to sign my advance directives.”
C. “My doctor will need to provide approval for the decisions outlined in my living will.”
D. “My durable power of attorney for healthcare is part of my advance directives.”
Answer: D. “My durable power of attorney for healthcare is part of my advance directives.”
A nurse is chairing a committee about preventing infant abduction in a new birth care center.
Which of the following quality control tasks should the nurse assign to be completed first?
A. Identify the industry standards for infant safety
B. Evaluatethe selected infant safety system
C. Choose an infant safety system
D. Establish measurement criteria for infant safety systems
Answer: A. Identify the industry standards for infant safety
A nurse notes that a client is eating about half of the food on his plate and coughs frequently
during meals. The nurse plans to perform dysphagia screening to determine the client's need
for a referral to which of the following providers?
A. Physical therapist
B. Respiratory therapist
C. Speech therapist
D. Occupational therapist
Answer: C. Speech therapist
A nurse manager is planning to assign care for four clients on a medical surgical unit. Which
of the following clients should the nurse assign to a LPN?
A. An older adult who has lung cancer and has periodic episodes of severe dyspnea
B. A middle adult client who has a below the knee amputation and requires a dressing change
C. A young adult client who is postoperative, receiving morphine via epidural, and report
spruritus

D. An adolescent who requires teaching regarding insulin administration
Answer: B. A middle adult client who has a below the knee amputation and requires a
dressing change
While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that six of the 15 records lack documentation regarding advance directives.
Which of the following is the priority for the nurse to take?
A. Remind nurses to obtain this information during the admission process
B. Reinforce the potential consequences of not having his information on record to the
nursing staff
C. Meet with nursing staff to review the policy regarding advance directive
D. Ask nurse who are caring for client without his information in the medical record to obtain
it
Answer: C. Meet with nursing staff to review the policy regarding advance directive
A nurse is caring for a group of clients. Which of the following should the nurse see first?
A. A client who is postoperative and has a fever.
B. A client whose pressure ulcer has serosanguineous drainage on the dressing
C. A client who has diabetes mellitus and is diaphoretic
D. A client who has a fractured hip and reports a pain level of 7 on a scale from 0-10
Answer: C. A client who has diabetes mellitus and is diaphoretic
A nurse is receiving change-of-shift report for four clients. Which of the following clients
should he nurse care for first?
A. A client who is 4 hr postoperative following a hernia repair and has pitting edema of the
right leg
B. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhoea
C. A client who has pneumonia and requires a tracheostomy dressing change
D. A client who has a new colostomy and requires discharge teaching
Answer: A. A client who is 4 hr postoperative following a hernia repair and has pitting
edema of the right leg

A nurse manager discovers there is a conflict between nurses working the day shift and
nurses working on the night shift. Which of the following actions should the nurse manager
take first?
A. Acknowledge the conflict and encourage the nurses to focus on working as a team
B. Gather information regarding the situation
C. Encourage the nurses to resolve the conflict autonomously
D. Meet with a committee from each shift to discuss issues related to the conflict
Answer: B. Gather information regarding the situation
A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid
chemical in an industrial setting. Which of the following actions should the nurse take first?
A. Don personal protective equipment
B. Irrigate the exposed area with water
C. Remove the client’s clothing
D. Report the incident to OSHA
Answer: A. Don personal protective equipment
A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong
client. Which of the following actions should the nurse perform first?
A. Complete an incident report
B. Measure the client’s vital signs
C. Inform the nurse manager
D. Call the provider
Answer: A. Measure the client’s vital signs
A home health nurse is assessing the home environment during an initial visit to a client who
has a history of falls. Which of the following findings should the nurse identify as increasing
the client's risk for falls? (SATA) [repeat]
A. A wheeled office chair at the client's computer desk
B. A raised vinyl seat on the toilet in the bathroom
C. A throw rug covering some cracked floor
D. A folding chair without arm rests
E. A two wheeled walker used to assist the client with ambulation
Answer: A. A wheeled office chair at the client's computer desk

C. A throw rug covering some cracked floor
D. A folding chair without arm rests
A nurse is assessing a client who has meningitis. Which of the following findings should the
nurse report to the provider immediately?
A. Decreased level of consciousness
B. Generalized rash over trunk
C. Increased temperature
D. Report of photophobia
Answer: A. Decreased level of consciousness
A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance
with the care pathway, antibiotic therapy is prescribed. Which of the following situations
requires the nurse to complete a variance report with regard to the care pathway?
A. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.
B. A blood culture was obtained after antibiotic therapy had been initiated
C. An allergy to penicillin required an alternative antibiotic to be prescribed
D. The route of antibiotic therapy on the care pathway was changed from IV to PO
Answer: B. A blood culture was obtained after antibiotic therapy had been initiated
A nurse manager is making staffing assignments for the maternal newborn unit. Which of the
following clients should the nurse manager assign to a float nurse from the medical-surgical
unit?
A. A client who is post term and is receiving oxytocin for labor induction
B. A client who gave birth to her first child and requires instruction on breastfeeding
techniques
C. A client who is 2 days post-operative following a caesarean birth and is having difficulty
ambulating
D. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion
Answer: C. A client who is 2 days post-operative following a caesarean birth and is having
difficulty ambulating

A nurse is coordinating an interprofessional team to review proposed standards to reduce the
transmission of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following
members of the interprofessional team should the nurse consult?
A. Risk management coordinator
B. Clinical pharmacist
C. Nursing supervisor
D. Infection control nurse
Answer: D. Infection control nurse
A nurse is caring for a client who has uterine prolapse. The provider has recommended a total
abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which
of the following is an appropriate action for the nurse to take?
A. Discuss with the client her concerns regarding the procedure
B. Provide the client with information on treatment options and outcomes
C. Inform the client of the consequences of uterine prolapse and the need for intervention
D. Initiate a mental health consult to determine the client’s reasons for refusing surgery
Answer: A. Discuss with the client her concerns regarding the procedure
A nurse in the emergency department is assessing a client who is unconscious following a
motor- vehicle crash. The client requires immediate surgery. Which of the following actions
should the nurse take?
A. Delay the surgery until the nurse can obtain informed consent
B. Obtain telephone consent from the facility administrator before the surgery.
C. Ask the anaesthesiologist to sign the consent.
D. Transport the client to the operating room without verifying informed consent.
Answer: D. Transport the client to the operating room without verifying informed consent.
A nurse is planning to delegate client care assignment. Which of the following tasks should
the nurse plan to delegate to an assistive personnel?
A. Performing postmortem care prior to transferring the client to the morgue
B. Advising a client on self-administration of acetaminophen
C. Teaching a client to perform a finger-stick for testing blood glucose levels
D. Informing a family of a client’s progress in physical therapy
Answer: A. Performing postmortem care prior to transferring the client to the morgue

A nurse is working on a quality improvement team that is assessing an increase in client fall
at the facility. After problem identification, which of the following actions should the nurse
plan to take first as part of the quality improvement process?
A. Notify staff of the increased fall rate
B. Review current literature regarding client falls
C. Implement a fall prevention plan
D. Identify clients who are at risk of falls
Answer: D. Identify clients who are at risk of falls
A nurse is completing performance evaluation for an assistive personnel (AP). Which of the
following actions by the AP requires intervention by the nurse?
A. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile.
B. The AP closes the door of a client who is on airborne precautions.
C. The AP Removes cut flowers from the room of a client who is in protective environment.
D. The AP wears a mask when a caring for a client who has varicella.
Answer: A. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium
difficile.
A charge nurse notices that the staff nurse are having difficulty using new IV infusion pumps
for medication administration. Which of the following is priority action by the charge nurse?
A. Assess the staff nurse’s knowledge deficit.
B. Pair an inexperienced nurse with an experienced nurse.
C. Demonstrate use of the pump during medication administration.
D. Plan an in-service education program on the unit.
Answer: A. Assess the staff nurse’s knowledge deficit.
A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which of
the following tasks should the nurse assign to the AP?
A. Administer the initial bolus feeding to a client who has NG tube
B. Check a client pain level 30min after receiving acetaminophen
C. Collect urine specimen for newly admitted client
D. Instruct a client to splint an abdominal incisions
Answer: C. Collect urine specimen for newly admitted client

A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a
client. Which of the following actions should the nurse take?
A. Treat the client’s injuries within 30 min
B. Provide treatment for life-threatening injuries
C. Provide treatment for minor injuries
D. Allow the client to die without further intervention
Answer: B. Provide treatment for life-threatening injuries
A home health nurse is performing a safety assessment of a client’s home. Which of the
following findings should the nurse identify as a safety hazard?
A. The client has used tracks to secure the carpet on the stairs
B. The client’s electrical cord is taped to the floor
C. The client’s bedside lamp is plugged in using an extension cord with two prongs
D. The client stores cleaning supplies in a locked cabinet above his head
Answer: C. The client’s bedside lamp is plugged in using an extension cord with two prongs
A charge nurse is observing a newly licensed nurse provide care for a client who has
Clostridium difficile infections. Which of the following actions by the newly licensed nurse
indicate an understanding of proper infection control procedures?
A. Applies a mask before entering the client’s room(It’s contact precaution)
B. Removes fresh flowers from the client’s room.
C. Washes her hands with an alcohol-based handrub after caring for the client.(no, ineffective
and must wash hands with soap/water)
D. Wears gown when caring for client
Answer: D. Wears gown when caring for client
A nurse is preparing discharge planning for a client who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following supplies to manage
tracheostomy at home? (SATA)
A. Pipe cleaners
B. O2 Tank
C. Cotton balls
D. Petroleum Jelly

E. Obturator
Answer: A. Pipe cleaners
B. O2 Tank
E. Obturator
A nurse is caring for four clients who are scheduled to undergo surgery. Which of the
following clients can give informed consent?
A. An adult client who has alcohol intoxication
B. An adolescent client who is legally emancipated
C. An older adult client who has questions about the procedure
D. An adult client who has moderate Alzheimer’s disease
Answer: B. An adolescent client who is legally emancipated
A nurse is discussing the safekeeping of valuables with a client who is scheduled for surgery.
Which of the following client statements indicates the need for further teaching?
A. “I can wear my ankle bracelet since I am just having a local anesthetic:
B. “I can leave my wedding ring on if it is taped in place”
C. “I should remove my dentures before the procedure”
D. “I should leave my valuables with a family member”
Answer: B. “I can leave my wedding ring on if it is taped in place”
A nurse is caring for an older adult client who has Stage III pressure ulcer. The nurse requests
a consultation with the wound care specialist. Which of the following actions by the nurse is
appropriate when working with a consultant?
A. Request the consultation after several wound care treatments are tried
B. Arrange for the wound care nurse specialist to see the client daily to provide the
recommended treatments
C. Arrange the consultation for a time when the nurse caring for the client is able to be
present for the consultation
D. Provide the consultant with subjective opinions and beliefs about the client’s wound care
Answer: C. Arrange the consultation for a time when the nurse caring for the client is able to
be present for the consultation

A nurse is observing an AP administer 0.9% sodium chloride enema to an adult client. For
which of the following actions by the AP should the nurse intervene?
A. Positions the client on her left side with knees flexed
B. Administers the solution at room temp
C. Points tubing in the direction of the umbilicus during insertion
D. Inserts the tubing 8cm(3.1 in) into the rectum
Answer: A. Positions the client on her left side with knees flexed
A nurse is orienting a newly licensed nurse about client confidentiality. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “I should encrypt personal health information when sending emails.”
B. “I can post the client’s vital signs in the client’s room.”
C. “I can use another nurse’s password as long as I log off after using the computer”
D. “I should discard personal health information documents in the trash before leaving the
unit”
Answer: A. “I should encrypt personal health information when sending emails.”
A nurse is participating on a committee that is considering the creation of a policy that will
allow the nurses to remove chest tubes. Which of the following is an appropriate resource for
the nurse to consult in planning for this policy? (2016 practice)
A. ANA Standards of Practice
B. ANA Code of Ethics
C. State Nurse Practice Act
D. Institute of medicine
Answer: C. State Nurse Practice Act
A charge nurse observe a licensed practical nurse tell a client that she will return with a
medication to help relieve the client’s nausea. The LPN does not return with the medication.
The charge nurse should reinforce which of the following ethical principles with the LPN?
A. Veracity
B. Justice
C. Fidelity
D. Nonmaleficence
Answer: C. Fidelity

A nurse administrator is using benchmarking as control criteria while reviewing current
policies and procedures. Which of the following actions should the nurse take?
A. Use root cause analysis to identify gaps in meeting standards- root cause analysis is done
if the benchmark is not met
B. Establish work initiatives to promote a positive environment
C. Compare practices with in the facility against other high-performing facilities
D. Determine how current practice will affect future performance within the facility
Answer: C. Compare practices with in the facility against other high-performing facilities
A nurse enters a client’s room and identifies that the client is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the
nurse take first?
A. Place a faulty equipment tag on the pump
B. Notify the provider
C. Auscultate the client’s lungs
D. Complete an incident report
Answer: C. Compare practices with in the facility against other high-performing facilities
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the
surgical suite. Which of the following nursing statements is an appropriate nursing response?
A. “It’s not too late to cancel the surgery if you want to”
B. “Why did you make the decision to have this procedure?”
C. “This won’t take long and it will be over before you know it”
D. “You shouldn’t be worried because the procedure is very safe”
Answer: A. “It’s not too late to cancel the surgery if you want to”
A facility infection control nurse is reviewing the reports of a group of clients. Which of the
following infections should the nurse report to the public health department?
A. Lyme disease
B. Bacterial conjunctivitis
C. Health care-acquired pneumonia
D. MRSA
Answer: A. Lyme disease

A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of
the following information should the nurse include in the change-of-shift report?
A. The steps to follow when providing wound care
B. The client’s preferred time for bathing
C. The belief that the client has a difficult relationship with his son
D. The time the client received his last dose of pain medication
Answer: D. The time the client received his last dose of pain medication
A nurse receives a new prescription over the telephone from a client’s provider. Which of the
following actions should the nurse take first?
A. Write down the complete prescription
B. Read back the prescription to the provider
C. Document the prescription as a telephone prescription in the medical record
D. Ensurethat the provider signs the prescription
Answer: A. Write down the complete prescription
A charge nurse witnessed an assistive personnel failing to follow facility protocol when
discarding contaminated linens. Which of the following actions should the nurse take first?
A. Discuss the issue with the AP
B. Notify the unit manager about the incident
C. Reinforce facility protocols at the next staff meeting
D. Alert the infection control department
Answer: A. Discuss the issue with the AP
A nurse is planning care for a client who is disoriented and has a history of wandering. Which
of the following actions should the nurse include in the plan?
A. Raise all four side rails on the client’s bed
B. Remove the clock and calendar from the client’s room
C. Obtain a prescription for a sedative for the client
D. Provide distractions for the client during the day
Answer: D. Provide distractions for the client during the day

A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following
actions should the nurse take?
A. Initiate contact precautions (standard)
B. Report the infection to the local health department
C. Apply an antiviral cream to lesions
D. Instruct the client to use condoms until the treatment is completed
Answer: B. Report the infection to the local health department
A nurse is teaching a class of newly licensed nurses about evidence-based practices. The
nurse should include which of the following as the first step in evidence-based practice?
A. Apply research to client care practice
B. Develop a clinical question
C. Critically assess the evidence
D. Collect evidence from a variety of sources
Answer: B. Develop a clinical question
A nurse assumes the leading role on the hazardous materials team immediately following a
chemical mass casualty incident in the community. As clients arrive at the designed triage
area outside the hospital, which of the following actions should the nurse take?
A. Place shower caps over the client’s’ hair
B. Remove contaminated clothing
C. Scrub the client’s skin with betadine solution
D. Admit the injured clients to positive-pressure rooms
Answer: B. Remove contaminated clothing
A case manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse
manager should identify that which of the following torts has occurred?
A. Libel
B. Negligence
C. Battery
D. Slander
Answer: A. Libel

A nurse is preparing to complete morning assignments on several assigned clients. Which of
the following clients should the nurse plan to assess first?
A. A client who had a bladder scan that indicated 250 mL of urine in the bladder
B. A client who is 3 days postoperative and who’s dressing has serosanguinous drainage
C. A client who has diabetes and an early morning blood glucose of 220 mg/dL
D. A client who has a nasogastric tube to intermittent suction and reports nausea
Answer: D. A client who has a nasogastric tube to intermittent suction and reports nausea
A charge nurse overhears a staff nurse discussing a client’s diagnosis in the cafeteria. Which
of the following responses should the charge nurse make?
A. “Please stop discussing the client in a public area”
B. “Do you understand the HIPAA regulations?”
C. “We should discuss your concerns with the client’s care team”
D. “I will notify The client’s provider about this breach of confidentiality
Answer: D. A client who has a nasogastric tube to intermittent suction and reports nausea
A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which
of the following actions should the nurse preceptor identify as maintaining sterile technique?
A. Places sterile gauze 1.3cm(0.5 in) away from the edge of a sterile drape
B. Uses sterile forceps to pack sterile gauze into the wound
C. Sets up the sterile field 30 min prior to performing the dressing change
D. Uses a sterile-gloved hand to adjust the back of the sterile gown.
Answer: B. Uses sterile forceps to pack sterile gauze into the wound
A nurse working in a long-term care facility is assessing an older adult client who has been
receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the
following actions should the nurse take?
A. Place the client in a negative-pressure airflow room
B. Perform hand hygiene with alcohol based hand sanitizer.
C. Clean the equipment in the client’s room with bleach.
D. Initiate droplet precautions for the client.
Answer: C. Clean the equipment in the client’s room with bleach.

A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is
having trouble focusing and has difficulty completing care for his assigned clients. Which of
the following interventions is appropriate?
A. Advise him to complete the less time-consuming tasks first
B. Recommend that he take time to plan at the beginning of his shifts
C. Offer to provide care for his clients while he takes a break
D. Ask other staff members to take over some of his tasks
Answer: B. Recommend that he take time to plan at the beginning of his shifts
A nurse is planning discharge for a client who has lung resection. The nurse initiates a referral
fora social worker. Which of the following assessment data supports this referral?
A. The client needs to have someone bring O2 tanks and equipment to her home
B. The client needs to have range-of-motion exercises to assist with ambulation
C. The client needs to arrange financial resources to purchase equipment
D. The client needs to have someone come in to help her bath eat home
Answer: C. The client needs to arrange financial resources to purchase equipment
A nurse initiates a referral to an occupation therapist for a client who has rheumatoid arthritis.
Which of the following assessment findings supports the need for this referral?
A. The client reports pain when chewing solid foods.
B. The client expresses the desire to join a support group.
C. The client requires assistance with completing oral hygiene
D. The client has difficulty ambulating with a walker
Answer: C. The client needs to arrange financial resources to purchase equipment
A nurse is caring for a client who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted in regard to this client’s care? (SATA)
A. Nutritional therapists
B. Case Manager
C. Mental Health counselor
D. Occupational therapist
E. Physical therapist
Answer: A. Nutritional therapists
B. Case Manager

C. Mental Health counselor
A nurse is prioritizing care after a receiving change-of-shift report on four clients. Which of
the following clients should the nurse assess first?
A. A client who reports a headache with sensitivity to light.
B. A client who reports feeling lightheaded when he stands up from a lying position
C. A client who reports indigestion and pain in her jaw
D. A client who reports an urge to void but has not urinated during the prior shift
Answer: C. A client who reports indigestion and pain in her jaw
A nurse on an acute mental health unit is assessing four clients. Which of the following
clients is the highest priority?
A. A client who has depressive disorder and has poor personal hygiene
B. A client who has dementia and exhibits aphasia
C. A client who has bipolar disorder and displays constant pacing
D. A client who has schizophrenia and uses neologisms
Answer: C. A client who has bipolar disorder and displays constant pacing
A nurse is planning care for a group of clients. Which of the following action should the
nurse take first?
A. Obtain a breakfast tray for a client whose total parenteral nutrition was discontinued 4 hrs
ago.
B. Auscultate the bowel sounds of a client who has not had bowel movement after taking a
laxative 12hr ago.
C. Provide instruction to the caregiver of a client who has dementia and new diagnosis of
diabetes mellitus.
D. Check a client who has a leg cast and reports a new onset of pain.
Answer: D. Check a client who has a leg cast and reports a new onset of pain.
A nurse on a medical surgical unit is caring for a client who asks about advance directives
and states that he wants to appoint a health care proxy. Which of the following responses
should the nurse make?
A. “You must choose a member of your family to serve as a your health care proxy.”
B. “A health care proxy can make decisions for you when you are unable to do so.”

C. “You should appoint a health care proxy before undergoing an invasive procedure.”
D. “It is necessary for an attorney to approve your health care proxy.”
Answer: B. “A health care proxy can make decisions for you when you are unable to do so.”
A nurse in a rehabilitation facility is administering medications to a client who was admitted
earlier that day. The client refuses two of the medications, stating, “I’ve never taken these
before.” Which of the following actions should the nurse take first?
A. Consult the pharmacist about the client’s prescribed medications.
B. Compare the client’s medication administration record with the prescriptions on the
transfer orders.
C. Review the intended purpose of the prescribed medication with the client.
D. Call the provider to clarify the clients prescribed medications.
Answer: B. Compare the client’s medication administration record with the prescriptions on
the transfer orders.
A nurse on a med surgical unit is caring for four clients. The nurse should recognize that
which of the following clients is the highest priority?
A. A client who is postoperative following laminectomy 12hrs ago is unable to void
B. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy
C. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38C (101F)
Answer: C. A client who has peripheral vascular disease and has an absent pedal pulse in the
right foot
A nurse in the emergency department admits a client who has been exposed to cutaneous
anthrax. Which of the following actions should the nurse take?
A. Plan to administer an antiviral medication to the client.
B. Wear an N95 respirator mask while caring for the client.
C. Prepare to administer antibiotics to the client.
D. Place a surgical mask on the client during transfer to the unit.
Answer: C. A client who has peripheral vascular disease and has an absent pedal pulse in the
right foot

A charge nurse notices that two staff nurses are not taking meal breaks during their shifts.
Which of the following actions should the nurse take first?
A. Discuss the time management strategies with the nurses
B. Review facility policies for taking scheduled breaks.
C. Provide coverage for the nurses’ breaks
D. Determine the reasons the nurses are taking scheduled breaks.
Answer: D. Determine the reasons the nurses are taking scheduled breaks.
A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse
distracts the client and quickly administers the injection. This illustrates which of the
following?
A. False imprisonment
B. Libel
C. Assault
D. Battery
Answer: D. Battery
A nurse is speaking with a visitor who asks a question about the status of a relative who is a
client on the unit. Which of the following responses by the nurse is appropriate?
A. “I’m not taking care of your relative today, so I don’t have the latest information”
B. “I will have your relative’s nurse come and talk with you about her care.”
C. “Let me check your relative’s medical record to see how she’s doing.”
D. “Please ask your relative about this, because I cannot share information about her.”
Answer: D. “Please ask your relative about this, because I cannot share information about
her.”
A nurse suggests respite care for the partner of a client who has mild cognitive impairment.
The client’s partner asks the nurse how that would help. The nurse should explain the respite
care would do which of the following?
A. Allow her to take time off from attending to her partner
B. Provide volunteers who will run errands for her
C. Send a clinician to assess the safety of leaving her partner alone
D. Help her arrange transferring her partner to an assisted living facility

Answer: A. Allow her to take time off from attending to her partner
A charge nurse observes a client fall during ambulation and notes that his gait belt was not in
place. In reviewing the incident report, the nurse finds no mention of a gait belt. Which of the
following ethical principles should guide the nurse’s subsequent actions?
A. Non maleficence
B. Veracity
C. Fidelity
D. Beneficence
Answer: B. Veracity
A nurse is caring for a client who is scheduled for placement of a central venous access
device. Which of the following actions is the nurse’s responsibility in the informed consent
process?
A. Place a photocopy of the signed consent in the client’s medical record
B. Review the risks and benefit of the procedure with the client
C. Discuss alternative treatment options with the client
D. Assess the client’s understanding after the provider has talked with her
Answer: D. Assess the client’s understanding after the provider has talked with her
A nurse is providing teaching to an assistive personnel about the application of wrist
restraints toa client. Which of the following instructions should the nurse include in the
teaching?
A. Remove the client’s restraints every 2 hr.
B. Allow 1 fingerbreadth between there strain and the client’s wrists
C. Attach the restraints to the fixed portion of the frame of the client’s bed
D. Secure the client’s restrains with a square knot
Answer: A. Remove the client’s restraints every 2 hr.