2020 ATI RN Leadership Proctored Exam With Answers-311 Solved Questions

NGN ATI RN LEADERSHIP PROCTORED EXAM 2020 VERSION 70
QUESTIONS WITH VERIFIED SOLUTIONS/A+ GRADE
1. 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?
Answer: A client who is at 35 weeks of gestation and has a biophysical profile of 6
2. A nurse is preparing to discharge a client who has end stage heart failure. The client's partner
tells the nurse she can no longer handle caring for the client. Which of the following actions
should the nurse take?
Answer: Contact the case manager to discuss discharge options
3. 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?
Answer: Social worker
4. 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?
Answer: Instructing the client to place their chin to chest while swallowing
5. 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?
Answer: “A nurse can disclose information to a family member with the client’s permission.”
6. 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?
Answer: Contact social services about the delivery of the oxygen equipment.

7. 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
responses by the nurse is appropriate?
Answer: I understand, and it’s not too late to change your mind.
8. 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?
Answer: Contact the nurse manager
9. A nurse is assessing a client who has meningitis. Which of the following findings should the
nurse report to the provider immediately?
Answer: Decreased level of consciousness
10. 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?
Answer: Contact family members to come sit with the client
11. 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 interventions is appropriate?
Answer: Recommend that he take time to plan at the beginning of his shift.
12. A nurse is preparing to delegate bathing and turning of a newly admitted client who has end
stage bone cancer to an experienced AP. Which of the following assessments should the nurse
make before delegating care?
Answer: Has data been collected about specific client needs related to turning?
13. A nurse is participating in the development of a disaster management plan for a hospital. The
nurse should recognize which of the following resources is the highest priority to have available
in response to a bioterrorism event?
Answer: A sufficient supply of personal protective equipment.

14. A nurse manager observes an assistive personnel incorrectly transferring a client to the
bedside commode. Which of the following actions should the nurse take first?
Answer: Help the AP transfer the patient
15. A nurse manager is leading discussion about ethical dilemmas. Which of the following
situations should the nurse manager include as an example of an ethical dilemma?
Answer: a parent wants a 14-year-old adolescent to receive radiation treatment against his will
16. A nurse a caring for a client who request information about the prevalence of Tay-Sachs
disease. Which of the following resources should the nurse use to obtain this information?
Answer: An evidence-based nursing journal
17. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the
following a statement by the newly licensed nurse indicates an understanding of the teaching?
Answer: I should encrypt personal health information when sending email.
18. 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?
Answer: Transport the client to the operating room without verifying informed consent.
19. A nurse enters a clients 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?
Answer: Inform the provider that the client requires clarification about the procedure
20. A case manager is preparing a discharge plan for a client following coronary artery by pass
grafting surgery. Which of the following client issues should the nurse address first?
Answer: Inadequate food supply

21. 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?
Answer: Pertussis
22. A nurse is preparing to complete an incident report regarding a medication error. Which of
the following actions should the nurse plan to take SATA.
Answer: Place a copy of the completed report in the client’s medical record
Include the time the medication occur in the report, identify the medication name and dosage
administered to the client in the record
23. A nurse tells the unit manager, "I am tired of all the changes on the unit. If things don't get
better, I'm going to quit." Which of the following responses by the unit manager is appropriate?
Answer: So, you are upset about all the changes on the unit?
24. 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?
Answer: Determine the reasons the nurses are not taking scheduled breaks
25. A client has a new permanent pacemaker inserted. Which of the following home care
instructions should the nurse include?
Answer: Swimming could cause the unit to have an electrical short
26. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
Answer: I will wear a cover gown when caring for a client who has herpes simplex
27. A staff nurse is supervising a newly licensed nurse who is preparing to administer an
intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse
is appropriate?
Answer: Checking residual volume before each feeding

28. A nurse is preparing an education program about professional codes of ethics for nurses,
Which of the following information should the nurse plan to include?
Answer: A code of ethics is a set of principles for nursing practice
29. A nurse receives change-of-shift report for the following four clients. Which of the following
clients should the nurse assess first?
Answer: An older adult client who has bacterial pneumonia and a new onset of restlessness
30. A charge nurse is assessing staff knowledge about safety procedures regarding needlestick
injuries. Which of the following statements by a nurse indicates appropriate understanding of
these safety procedures?
Answer: An incident report should be completed if a client receives a stick from her own used
needle
31. 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 which of the following torts has occurred?
Answer: Libel
32. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist
restraints to a client who is agitated and does not have a prescription for restraints. Which of the
following actions should the nurse take first?
Answer: Remove the restraints from the client's wrists
33. To resolve 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 whoop
pose those changes. Which of the following conflict resolution strategies is the nurse manager
using?
Answer: Competing

34. A nurse is caring for a client and notices fraying on the electrical cord of the client's IV
pump. Which of the following actions is the priority for the nurse to take?
Answer: Remove the IV pump from the client's room
35. 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?
Answer: Social worker
36. A charge nurse is completing client care assignments. Which of the following assignments is
appropriate for a licensed practical nurse?
Answer: A client who is 1 day postoperative and has a continuous bladder irrigation
37. A nurse is caring for a client who is comatose and has advance directives designating his
adult daughter as his health care proxy. The client's partner instructs the nurse to institute CPR if
the client experiences cardiac arrest. Which of the following actions should the nurse take?
Answer: Inform the partner that the staff must follow the client's advance directives
38. A nurse in the emergency room is assessing several clients. Which of the following is the
highest priority?
Answer: A client who reports SOB and left neck and shoulder pain.
39. A nurse is providing a change-of-shift report for an oncoming nurse. Which of the following
information should the nurse include in the report?
Answer: “The client is currently in the radiology department for a chest x-ray.”
40. A nurse is discussing critical pathway use during a staff meeting. Which of the following
information should the nurse manager include as an outcome of critical pathway use?
Answer: Decreased care delays

41. A nurse is providing instructions about chemotherapy for a client who has a new diagnosis of
breast CA. The client has decided to try an alternative treatment rather than starting
chemotherapy. Which of the following actions should the nurse take?
Answer: Respect the client’s decision about not receiving chemotherapy.
42. A nurse is planning to develop a standard for removal of indwelling urinary catheters from
clients following a colon resection. Which of the following resources should the nurse use?
Answer: Critical pathway
43. A nurse is admitting a client who is scheduled for cholecystectomy. The client does not speak
English and is accompanied by her adult daughter. Which of the following actions should the
nurse take?
Answer: Access a language line to interpret what is being said
44. A charge nurse is making room for new admissions following a community disaster. which of
the following clients should the nurse recommend for discharge?
Answer: A client who has a DVT and INR of 2.0
45. A nurse from the labor and delivery unit is assigned to float to a medical-surgical unit. Which
of the following actions should the nurse take first?
Answer: Request orientation to the medical-surgical unit
46. 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 record?
Answer: Morphine sulfate 10mg q 4h IV prn for pain
47. A nurse on a medical surgical unit is caring for a group of clients with assistance of a licensed
practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse
assign to the LPN?
Answer: Reinforcing dietary teaching with a client who has heart disease

48. A nurse is planning for four clients who were classified using a disaster triage tag system
following a mass casualty event. Which of the following clients should the nurse identify as the
priority?
Answer: A client who has a red tag
49. A nurse enters a client’s room and observes a fire in the trash can. Identify the sequence of
actions the nurse should take.
Answer: Remove the client from the area
50. A nurse witnesses a coworker not following facility procedure when discarding the unused
portion of a controlled substance. Which of the following actions should the nurse take? (SATA)
Answer: Submit an incident report to the risk manager. d. Document a factual account of the
incident. e. Identify all witnesses to the incident
51. A nurse is caring for a group of clients who are receiving physical therapy. Which of the
following information regarding a client should the nurse report to the physical therapist?
Answer: A client has new a diagnosis of colorectal cancer
52. 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?
Answer: A primigravida client who is 1-day postoperative following a Cesarean section and has
a PCA pump.
53. A charge nurse overhears a provider and a nurse talking about a client’s diagnosis in the
cafeteria. Which of the following actions should the nurse take first?
Answer: Remind them that client information is confidential
54. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks
should the nurse assign to the AP?
Answer: Tag a malfunctioning piece of equipment as broken

55. A nurse is teaching a newly licensed nurse about hazardous and infectious materials. Which
of the following situations should the nurse include as a safe handling technique?
Answer: A nurse places a mask on a client with tuberculosis before transport to the radiology
department
56. A client who is unconscious and has extensive internal injuries arrives via ambulance to the
emergency room. The staff cannot reach the client’s family. Which of the following permits the
staff to proceed with emergency surgery?
Answer: Implied consent
57. A nurse is teaching a newly licensed nurse about the purpose of interdisciplinary conferences.
the nurse should identify which of the following client’s needs an interdisciplinary conference?
Answer: A client who has a recent stroke and is showing manifestations of depression
58. A nurse is caring for a client who is scheduled for a hysterectomy and has signed the
informed consent form. The client tells the nurse that she is unsure about having the procedure.
Which of the following responses should the nurse make?
Answer: If you have any concerns about the procedure, the surgery can be canceled
59. A nurse on a medical-surgical unit is delegating client care. Which of the following tasks
should the nurse delegate to assistive personnel?
Answer: Using a pain rating scale to monitor a client’s pain level
60. A nurse manager is reviewing the nursing code of ethics with the staff nurse. Which of the
following statements by nurse indicate understanding of the teaching? (SATA)
Answer: • I can delegate the removal of an IV catheter to an LPN on the unit.
• I administer pain medication to my client seven if they have a history of narcotic addiction.
• I will attend continuing education classes for professional growth.

61. 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?
Answer: Client who is at risk of pressure ulcers and has albumin level of 4.2
62. A nurse is caring for a client who is scheduled for coronary artery bypass surgery and does
not wish to have any blood transfusions. The nurse should recognize that administering blood to
the client is a violation of which of the following ethical principles?
Answer: Autonomy
63. A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings
should the nurse identify as a need for referral to speech-language pathology?
Answer: Impaired voluntary cough
64. A nurse in the ER department is assessing a preschool-age child who has bruises on both
arms and a spiral fracture of the left ulna. The child’s parents tell the nurse that the child tripped
over some toys and fell down. Which of the following actions should the nurse take?
Answer: Report the child’s injuries to CPS
65. A charge nurse is teaching a group of nurses about the purpose of a living will. Which of the
following information about living wills should the charge nurse include in the teaching?
Answer: Addresses resuscitation measures
66. A nurse is caring for a client who has CA. The client’s adult child asks the nurse for info
about the client’s treatment plan. Which of the following responses should the nurse make?
Answer: I cannot provide this information to you without your mother’s consent
67. A nurse is participating in an interdisciplinary conference for a client who has heart failure,
reports limited resources and lives alone. Which of the following actions is the nurse’s priority?
Answer: Coordinate the team and the plan of care

68. A nurse is caring for a client who has increased intracranial pressure and is receiving IV
corticosteroids. Which of the following information is most important for the nurse to report at
shift change?
Answer: Glasgow Coma Scale score
69. A nurse is preparing to transfer a client from the emergency department to a medical-surgical
unit using the SBAR communication tool. Which of the following information should the nurse
include in the background portion of the report?
Answer: The client’s vital signs
70. 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?
Answer: Inadequate food supply
71. A charge nurse is supervising the actions taken by a staff nurse following a client fall. The
charge nurse should identify which of the following actions by the staff nurse indicates an
understanding of the procedure?
Answer: Includes the client’s account of the fall in the incident report
72. A nurse is caring for a client who has been admitted and diagnosed with type 1 diabetes
mellitus. The client tells the nurse that she has decided to go home. Which of the following
actions should the nurse take?
Answer: Have the client sign the Against Medical Advice Form
73. A nurse is planning care for a group of clients in a medical-surgical unit. Which of the
following tasks should the nurse delegate to an assistive personnel?
Answer: Measuring a client's hourly intake and output
74. A facility has identified an increase in healthcare-associated urinary tract infections(UTIs) on
the medical-surgical unit. A nurse is participating in a quality improvement process to address
this problem. Which of the following should be the first step in the process?

Answer: Establish best practice guidelines for reducing the incidence of UTIs.
75. A nurse manager observes a newly licensed nurse and an assistive personnel (AP) arguing
about the failure of the AP to restock unit supplies. The AP leaves the room. Which of the
following is an appropriate statement at this time by the nurse manager to the newly licensed
nurse?
Answer: "I would like for you to approach the AP to resolve the problem."
76. A client is brought to the emergency department following a motor-vehicle crash. Drug use is
suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to
provide the specimen. Which of the following is the appropriate action by the nurse?
Answer: Document the client's refusal in the chart.
77. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate
to assign to a licensed practical nurse?
Answer: Administer a nasogastric tube feeding.
78. A nurse preceptor is evaluating a newly licensed nurse's competency in assisting with a
sterile procedure. Which of the following actions indicates the newly licensed nurse is
maintaining sterile technique? (SATA)
Answer: • Opens the sterile pack by first unfolding the top lap away from her body
• Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
79. 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?
Answer: Auscultate the client’s lungs.
80. A nurse is planning care for a group of clients and can delegate care to a licensed practical
nurse (LP) and an assistive personnel. Which of the following tasks should the a nurse assigned
to the LPN?

Answer: Reinforcing teaching with a client who is learning to self-administer insulin
81. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After
donning a sterile gown and gloves, which of the following actions by the newly licensed nurse
does the nurse demonstrate correct aseptic technique?
Answer: The nurse holds her hands above her waist.
82. A nurse who is caring for a group of clients delegates collection of vital signs to an assistive
personnel (AP). Which of the following actions should the nurse take to evaluate the delegated
task?
Answer: Recheck vital signs that are outside the expected reference range.
83. A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
Answer: Obtaining a stool sample from a client who has renal failure
84. A nurse is triaging a group of clients following a disaster. Which of the following clients
should the nurse recommend for treatment first?
Answer: A client who has two open chest wounds with a left tracheal deviation
85. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which
of the following statements by a staff nurse indicates that the teaching was effective?
Answer: "Consent can be given by a durable power of attorney."
86. A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
Answer: An adolescent client whose parents refuse a blood transfusion for religious reasons
87. A nurse in an ambulatory care setting is orient 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?

Answer: Establishing communication between providers
88. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes. The
client expresses concern about the cost of blood-glucose monitoring supplies. Which of the
following actions should the nurse take?
Answer: Refer the client to the social services department.
89. A charge nurse is receiving a change-of-shift report. Which of the following situations should
the charge nurse address first?
Answer: The emergency department nurse is waiting to give report on a new admission.
90. A nurse who is precepting a newly licensed nurse is discussing the client assignment for the
shift. Which of the following actions should the nurse preceptor take first to demonstrate
appropriate time management?
Answer: Determine client care goals (set/plan goals)
91. A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which of
the following statements by a staff nurse indicates understanding?
Answer: “HIPAA allows clients to request a review of their own medical records.
92. 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?
Answer: Whether the client understands the risk of refusing the procedure
93. A charge nurse is planning the care of four newborns. An assistive personnel and licensed
practical nurse are available for staffing. Which of the following tasks should the nurse assign
toa licensed practical nurse?
Answer: Administer a hepatitis B vaccine.

94. During a staff meeting a unit manager reviews the results for documenting client education
and finds that they are below the benchmark. Which of the following strategies should the nurse
manager implement first?
Answer: Determine factors that interfere with the documentation of client education.
95. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain
that preventing client injury by removing a fall hazard demonstrates which of the following
ethical principles?
Answer: Nonmaleficence
96. A nurse is caring for a group of clients. Which of the following clients should the nurse plan
to assess first?
Answer: A client who has a nasogastric tube and has crackles in the lungs (ABC--airway)
97. A charge nurse is planning to evacuate clients on the unit because there is a fire on another
floor. Which of the following clients should the nurse evacuate first?
Answer: A client who is receiving IV chemotherapy and is ambulatory
98. A nurse enters the room of a client who is unconscious and finds that the client’s son is
reading her electronic medical records from a monitor located at the bedside. Which of the
following actions should the nurse take first?
Answer: Log out the computer so that the client’s son is unable to view his mother’s
information.
99. A nurse is preparing a client for cardiac catheterization. Just before the procedure, the client
asks the nurse about the risks of the procedure. Which of the following actions should the nurse
take?
Answer: Notify the provider about the client’s concerns.
100. A nurse is prioritizing care after receiving a change-of-shift report on four clients. Which of
the following clients should the nurse assess first?

Answer: A client who reports indigestion and pain in her jaw
101. 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?
Answer: Determine the reasons the nurses are not taking scheduled breaks. Assess first
102. A nurse is preparing to delegate bathing and turning of a newly admitted client who has endstage bone cancer to an experienced assistive personnel (AP). Which of the following
assessments should the nurse make before delegating care?
Answer: Has data been collected about specific client needs related to turning? (Assessment of
holistic care r/t pt needs and what the experienced AP can do)
103. A nurse is preparing to transfer a client from the emergency department to a medicalsurgical unit using the SBAR communication tool. Which of the following information should
the nurse include in the background portion of the report?
Answer: The client's vital signs
104. A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the
following statements by the client should the nurse identify as an indication that a referral to an
occupation therapist is necessary?
Answer: "I will need assistance with bathing."
105. A nurse in the emergency department is caring for a 16-year-old client who reports
abdominal pain and is accompanied by an adult neighbor. The provider diagnoses a ruptured
appendix and states that the client requires an emergency appendectomy. Which of the following
actions should the nurse?
Answer: Attempt to notify the client's guardian to obtain consent.
106. A nurse on a medical-surgical unit is caring for four clients. Which of the following findings
is the highest priority?

Answer: A client who had a cardiac catheterization whose capillary refill in the great toe is 4
seconds
107. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following
actions should the charge nurse take?
Answer: Collect data about the staff nurse to support further action.
108. A nurse is assessing a client's comprehension of a pulmonary function test prior to the
procedure. Which of the following client statements indicates to the nurse an understanding of
the procedure?
Answer: "I might have to wear a nose clip during this test."
109. A nurse in the emergency department is triaging four clients. Which of the following clients
should the nurse recommend to be examined first?
Answer: An older adult client who has dyspnea and a respiratory rate of 26/min
110. A home health nurse finds piles of newspapers in the hallway of a client's home. The nurse
explains the need to discard the newspapers for safety reasons. The client agrees to move the
newspapers into the living room. Which of the following conflict resolution strategies has the
nurse used?
Answer: Collaborating
111. A nurse is planning to delegate client care assignments. Which of the following tasks should
the nurse plan to delegate to an assistive personnel?
Answer: Performing post mortem care
112. A nurse is providing discharge teaching to a client following a total knee arthroplasty.
Which of the following information should the nurse include (SATA)
Answer: Contact information for the physical the rapiste. Information about follow-up care

113. A nurse is planning to discharge a client who has terminal cancer and suggests that the
family might benefit from respite services. When the client's partner asks how this service can
help, which of the following responses by the nurse is appropriate?
Answer: "It makes it possible for you to have some time away from caring for your wife."
114. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the
following instructions should the nurse include?
Answer: Warm the hands prior to piercing the skin.
115. A nurse is assessing a client who had a recent stroke. Which of the following findings
should indicate the need for referral to an occupational therapist?
Answer: Unilateral neglect -is one of the disabling features of stroke, and is defined as a failure
to attend to the side opposite a brain lesion.
116. A nurse is participating in the development of a disaster management plan for a hospital.
The nurse should recognize which of the following resources is the highest priority to have
available in response to a bioterrorism event?
Answer: A sufficient supply of personal protective Equipment
117. 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?
Answer: Pertussis
118. A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment used
for a client who has Clostridium difficile. Which of the following solutions should the nurse
recommend to clean the equipment?
Answer: Chlorine bleach
119. 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?

Answer: Ask the client's son to go to the waiting Area.
120. A nurse is completing discharge teaching with a client who is being treated for T). Which of
the following statements by the client indicates an understanding of the teaching?
Answer: "I should have a sputum culture done every 2 to 4 weeks."
121. An older adult client is awaiting surgery for a fractured right hip. The nurse should
recognize that which of the following can be delegated to an assistive personnel?
Answer: Recording the client's vital signs
122. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel
(AP).Which of the following is an appropriate task for the AP?
Answer: Obtain the weight of a newborn that is receiving formula
123. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the
following statements by the newly licensed nurse indicate an understanding of the teaching?
Answer: "I will remove a client's restraints every 4 Hours."
124. An infection control nurse is planning an education program for a group of newly licensed
nurses. Which of the following infections should the nurse include when discussing illnesses
requiring droplet precautions?
Answer: Mumps
125. A nurse is caring for a client who has cancer. The client and her partner are asking the nurse
about hospice care. Which of the following statements by the nurse is appropriate?
Answer: "Hospice care is a multidisciplinary program for clients who are terminally ill."
126. A nurse is planning care for a client who has Addison's disease. Which of the following
tasks should the nurse plan to delegate to an assistive personnel?
Answer: Remind the client to change positions slowly.

127. A charge nurse discovers that a staff nurse on the unit has made repeated medication errors.
Which of the following actions should the charge nurse take first?
Answer: Ask the nurse to describe her medication administration procedure. (1)
128. 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 which of the following torts has occurred?
Answer: Libel: talking bad about someone via writing it in notes
129. 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?
Answer: Place the client's ring in the facility safe.
130. A nurse is prioritizing postpartum care for four clients. Which of the following actions
should the nurse take first?
Answer: Check uterine tone for a client who received methylergonovine-if the uterine tone is not
131. 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?
Answer: Continue the medication dosages that relieve the client's pain
132. A nurse is observing an assistive personnel (AP) administer 0.9% sodium chloride enema to
an adult client. For which of the following actions by the AP should the nurse intervene?
Answer: Position the client on her left side with knees flexed
133. A nurse is providing information to a client about advance directives. The nurse should
explain that advance directives include which of the following?
Answer: Instructions regarding treatments the client desires or does not desire - (living wills and
durable power of attorney make up AD).

134. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize
which of the following clients is the highest priority?
Answer: A client who has peripheral vascular disease and has an absent pedal pulse in the right
foot
135. A staff development nurse is giving an in-service presentation about advocacy in nursing.
Which of the following statements by a nurse indicates an understanding of the role of a client
advocate?
Answer: "My role as a client advocate is to empower the clients to make informed healthcare
decisions."
136. A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the
bedside commode. Which of the following actions should the nurse take first?
Answer: Help the AP assist with transfer
137. A nurse at the local health department is caring for four clients who have communicable
diseases. Which of the following infections should the nurse report to the state health
department?
Answer: Chlamydia trachomatis
138. A charge nurse witnesses two nurses having a loud discussion at the nurses' station about
not wanting to care for a client who has drug-resistant tuberculosis. Which of the following
actions should the charge nurse take?
Answer: Contact the house supervisor to mediate the conflict
139. A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have
sufficient experiences to safely care for his assigned clients. Which of the following actions
should the nurse take?
Answer: Request that the charge nurse modify the assignment.

140. A nurse is conducting an in-service about the nursing code of ethics with a group of newly
licensed nurses. Which of the following information should the nurse include in the teaching as
an example of advocacy?
Answer: Recommending a referral for a client who requires physical therapy
141. A charge nurse in the emergency department is supervising a nurse who is floating from the
medical-surgical unit. Which of the following assignments is appropriate for the float nurse?
Answer: Perform a urinary catheterization for a client who has experienced a cerebrovascular
accident.
142. 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)
Answer: • A folding chair without armrests
• A wheeled office chair at the client's computer desk
• A throw rug covering some cracked vinyl flooring in the kitchen
143. A nurse in a long-term care facility should identify which of the following will provide
security for clients who have dementia?
Answer: Setting alarms on exits
144. 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?
Answer: Proceed with treatment without obtaining written consent (Implied Consent)
145. A nurse is reviewing the medication administration record of a client and notices that an
additional dose of medication has been administered. Which of the following actions should the
nurse take first?
Answer: Observe the client's condition.

146. 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.
Answer: Deep red color on the center of the client's wound
147. A nurse received a change of shift report at 0700 for four clients. Which of the following
actions should the nurse perform first?
Answer: Obtain a breakfast tray for a client who received a morning dose of insulin as part
148. 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?
Answer: A client who has multiple sclerosis and ataxia
149. A nurse is providing teaching to a client about advance directives. Which of the following
statements by the client indicate an understanding of the teaching?
Answer: "My durable power of attorney for health care is part of my advance directives*
150. 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?
Answer: Identify the industry standards for infant safety
151. 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 fora
referral to which of the following providers?
Answer: Speech therapist
152. A nurse manager is planning to assign care for four clients in a medical surgical unit. Which
of the following clients should the nurse assign to a LPN?
Answer: A middle adult client who has a below the knee amputation and requires a dressing

153. While auditing the medical records of clients currently in 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?
Answer: Meet with nursing staff to review the policy regarding advance directive
154. A nurse is caring for a group of clients. Which of the following should the nurse see first?
Answer: A client who has diabetes mellitus and is diaphoretic
155. A nurse is receiving a change-of-shift report for four clients. Which of the following clients
should the nurse care for first?
Answer: A client who is 4 hr postoperative following a hernia repair and has pitting edema of
the right leg
156. 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?
Answer: Gather information regarding the situation
157. 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?
Answer: Don personal protective equipment
158. 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?
Answer: Measure the client's vital signs
159. 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]
Answer: • A wheeled office chair at the client's computer desk
• A throw rug covering some cracked floor

• A folding chair without armrests
160. A nurse is assessing a client who has meningitis. Which of the following findings should the
nurse report to the provider immediately?
Answer: Decreased level of consciousness
161. 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?
Answer: A blood culture was obtained after antibiotic therapy had been initiated
162. 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?
Answer: A client who is 2 days postoperative following a cesarean birth and is having difficulty
ambulating
163. 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?
Answer: Infection control nurse
164. 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?
Answer: Discuss with the client her concerns regarding the procedure
165. 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?
Answer: Transport the client to the operating room without verifying informed consent.

166. A nurse is planning to delegate client care assignment. Which of the following tasks should
the nurse plan to delegate to an assistive personnel?
Answer: Performing postmortem care prior to transferring the client to the morgue
167. 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?
Answer: Identify clients who are at risk of falls
168. A nurse is completing performance evaluation for an assistive personnel (AP). Which of the
following actions by the AP requires intervention by the nurse?
Answer: The AP uses alcohol hand antiseptic after caring for a client who has Clostridium
difficile.
169. 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?
Answer: Assess the staff nurse's knowledge deficit.
170. 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?
Answer: Collect urine specimen for newly admitted client
171. 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?
Answer: Provide treatment for life-threatening injuries
172. 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?
Answer: The client's bedside lamp is plugged in using an extension cord with two prongs

173. 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?
Answer: Wears gown when caring for client
174. 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)
Answer: • Pipe cleaners
• O2 Tank
• 5 Obturator
175. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the
following clients can give informed consent?
Answer: An adolescent client who is legally emancipated
176. 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?
Answer: "I can leave my wedding ring on if it is taped in place"
177. 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?
Answer: Arrange the consultation for a time when the nurse caring for the client is able to be
present for the consultation
178. 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?
Answer: Positions the client on her left side with knees flexed

179. 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?
Answer: "I should encrypt personal health information when sending emails."
180. 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)
Answer: State Nurse Practice Act
181. 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?
Answer: Fidelity
182. A nurse administrator is using benchmarking as control criteria while reviewing current
policies and procedures. Which of the following actions should the nurse take?
Answer: Compare practices within the facility against other high-performing facilities
183. 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?
Answer: Auscultate the client's lungs
184. 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?
Answer: "It's not too late to cancel the surgery if you want to”
185. 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?
Answer: Lyme disease

186. 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?
Answer: The time the client received his last dose of pain medication
187. A nurse receives a new prescription over the telephone from a client's provider. Which of
the following actions should the nurse take first?
Answer: Write down the complete prescription
188. 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?
Answer: Discuss the issue with the AP
189. 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?
Answer: Provide distractions for the client during the day
190. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following
actions should the nurse take?
Answer: Report the infection to the local health department
191. 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?
Answer: Develop a clinical question
192. 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?
Answer: Remove contaminated clothing

193. 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 which of the following torts has occurred?
Answer: Libel
194. A nurse is preparing to complete morning assignments on several assigned clients. Which of
the following clients should the nurse plan to assess first?
Answer: A client who has a nasogastric tube to intermittent suction and reports nausea
195. 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?
Answer: “Please stop discussing the client in a public area”
196. 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?
Answer: Uses sterile forceps to pack sterile gauze into the wound
197. 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?
Answer: Clean the equipment in the client's room with bleach.
198. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse 15
having trouble focusing and has difficulty completing care for his assigned clients. Which of the
following interventions are appropriate?
Answer: Recommend that he take time to plan at the beginning of his shifts
199. A nurse is planning discharge for a client who has lung resection. The nurse initiates a
referral for a social worker. Which of the following assessment data supports this referral?
Answer: The client needs to arrange financial resources to purchase equipment

200. 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?
Answer: The client requires assistance with completing oral hygiene
201. 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)
Answer:
• Nutritional therapists
• Case Manager
• Mental Health counselor
202. 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?
Answer: A client who reports indigestion and pain in her jaw
203. A nurse in an acute mental health unit is assessing four clients. Which of the following
clients is the highest priority?
Answer: A client who has bipolar disorder and displays constant pacing - (Can lead to physical
exhaustion and death)
204. A nurse is planning care for a group of clients. Which of the following action should the
nurse take first?
Answer: Check a client who has a leg cast and reports a new onset of pain.
205. 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 health care proxy. Which of the following responses should the
nurse make?
Answer: “A health care proxy can make decisions for you when you are unable to do so.”

206. 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?
Answer: Compare the client's medication administration record with the prescriptions on the
transfer orders.
207. A nurse on a med surgical unit is caring for four clients. The nurse should recognize which
of the following clients is the highest priority?
Answer: A client who has peripheral vascular disease and has an absent pedal pulse in the right
foot
208. A nurse in the emergency department admits a client who has been exposed to cutaneous
anthrax.
Answer: Prepare to administer antibiotics to the client.
209. 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?
Answer: Determine the reasons the nurses are taking scheduled breaks.
210. 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?
Answer: Battery
211. 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?
Answer: “Please ask your relative about this, because I cannot share information about her.”
212. 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?
Answer: Allow her to take time off from attending to her partner

213. 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?
Answer: Veracity - commitment to tell the truth
214. 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?
Answer: Assess the client's understanding after the provider has talked with her
215. A nurse is providing teaching to an assistive personnel about the application of wrist
restraints to a client. Which of the following instructions should the nurse include in the
teaching?
Answer: Remove the client's restraints every 2 hr.
216. A nurse is reviewing a client's medication administration record and finds that the client has
not received a prescribed dose of warfarin for 2 days. Which of the following actions should the
nurse take first?
Answer: Check the client's INR.
217. A nurse manager is presenting an in-service about preventing read mission of clients dues to
complications following jolt arthroplasty, Which of the following leadership tasks is the nurse
performing?
Answer: Advocacy
218. A nurse is teaching an AP about caring for a client who has a DR order. Which of the
following statements by the AP Indicates an understanding of the teaching?
Answer: “I will call for the client's nurse to come to the room if I cannot detect the client's
pulse.”

219. The AP should contact the nurse for further assessment whenever a client's condition does
not meet expected findings, The client who has a DR order in place does not require
resuscitation.
Answer: A nurse is caring for four clients. Which of the following tasks can the nurse assign to
an APP Perform chest compressions on a client who is in cardiac arrest.
220. The nurse should assign an AP to perform chest compressions on a client who is In cardiac
arrest.
Answer: Performing basic CPR Is within an AP's range of function.
221. A Nurse is teaching a newly licensed nurse about using electronic medical records. Which
of the following statements by the newly licensed nurse indicated an understanding of the
teaching?
Answer: “My access to client electronic medical records may be tracked by my nurse manager”
222. A nurse is receiving a change-of-shift report. Which of the following clients should the
nurse assess first?
Answer: A client who had abdominal surgery 6 hours ago and had a heart rate of 120/min for the
last 2 hours.
223. A RN delegates the task of obtaining the bp of a client who is 2hr post-op following a
cholecystectomy to a LPN. The LPN reports a BP that is significantly higher than the client's
previous reading. Which of the following actions should the RN take first?
Answer: Recheck BP
224. A public health nurse is developing a list of recommendations for her supervisor on how to
use EBP to improve community outcomes. Which of the following should the nurse recommend
as a qualitative research method?
Answer: Phenomenology

225. A nurse at an urgent care clinic notices that a pain assessment is not being performed for all
clients as required by policy. Which of the following actions should the nurse take to ensure care
is provided according to policy?
Answer: Report this issue to the nurse manager
226. A nurse is teaching a client about advance directives. Which of the following statements by
the client indicates an understanding of the teaching?
Answer: “These will outline my wishes for medication treatment.”
227. A nurse is caring for a client who recently learned he has a mutation of the BRCA2 gene.
The client states that he does not plan to tell his adult children about the dx. Which of the
following responses displays clients advocacy by the nurse?
Answer: “Let's review what you understand about this test result.”
228. A nurse is caring for a client who has breast cancer and is deciding on a plan of treatment.
Which of the following statements should the nurse make?
Answer: “Let's talk about the benefits of each treatment.”
229. A nurse in a community health clinic is caring for four clients who each have a
communicable disease. Which of the following conditions is considered a nationally notifiable
infectious disease?
Answer: Chlamydia trachomatis
230. A staff nurse detects alcohol on the breath of another nurse working on the unit. The staff
nurse observes that the nurse's speech is slurred and their gait is unsteady. Which of the
following actions should the nurse take?
Answer: Notify the charge nurse of the nurse's behavior.
231. A nurse overhears two staff members in the facility elevator discussing a client's care.
Which of the following actions should the nurse take?
Answer: Report the incident to the nurse manager

232. A Nurse manager is reviewing the stages of conflict resolutions with the nursing staff. The
nurse manager should instruct the staff to expect the stages of conflict to occur in what order?
Answer:
STEPs: 1. Latent Conflict.
• Perceived Conflict
• Felt Conflict
• Manifest Conflict.
• Conflict Aftermath
233. A nurse is planning discharge care for a client who has rheumatoid arthritis and has
difficulty buttoning clothing. Which of the following referrals should the nurse recommend for
the client?
Answer: Occupational therapist
234. A nurse has just received a report on four clients on a med-surg unit. Which of the following
clients should the nurse plan to assess first?
Answer: A client who is post-op following a total knee arthroplasty and has a cap. refill of 4
secs.
235. A nurse is caring for several clients. Which of the following actions should the nurse take to
maintain client confidentiality?
Answer: Tell a client's partner that the client's lab test cannot be disclosed without permission.
236. A Charge Nurse is delegating tasks to a nursing unit that is short staffed. A client has a
prescription for wound irrigation twice per day. Which of the following actions should the CN
take?
Answer: Assign the procedure to a LPN
237. A nurse on a med-surg unit is terminally ill. Which of the following actions demonstrates
that the nurse is practicing in an ethical manner when caring for the client?

Answer: Discuss end-of-life goals with the client.
238. A nurse is teaching about the patient protection and affordable care act and their rights
regarding insurance coverage. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: “My insurance coverage no longer has lifetime coverage limits.”
239. A nurse is delegating tasks for a group of clients to an AP. Which of the following
statements by the nurse provides the right direction of communication with the AP?
Answer: “Tell me what time the client in room 205 voids for the first time after the catheter is
removed.”
240. A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within
the next 2hr. The client tells the nurse that she has called a taxicab and is leaving the hospital.
After notifying the surgeon, which of the following actions should the nurse take next?
Answer: Inform the client about the risks she may encounter by leaving the facility
241. A Charge Nurse is evaluating a plan of care that a newly licensed nurse developed for a
client who used to receive a continuous NG tube feeding. Which of the following interventions
should the CN ensure is part of the plan of care?
Answer: Use a 60ML syringe to flush out a clogged tube.
242. A CN is planning assignments for the upcoming shift. Which of the following tasks should
the CN delegate to an AP?
Answer: Assisting a client who had a hip arthroplasty to a chair.
243. A Nurse manager is conducting an annual performance review for a staff nurse. Which of
the following strategies should the nurse use in the review process? Select all that apply.
Answer: Include peer evals completed by other staff nurses, Have the nurse conduct a selfappraisal prior to review, Complete a performance checklist

244. A nurse manager is reviewing the actions a staff nurse took when they observed smoke
coming from the wastebasket in a client's room. The nurse manager should verify that the nurse
acted appropriately when they performed which of the following actions first?
Answer: Transported the client to the hallway.
245. A nurse is caring for a client who is experiencing adverse effects after receiving a new
medication. Which of the following communication tools should the nurse use for management
of this complication?
Answer: SBAR framework
246. A CN on a medical unit hears the fire alarm announcement that a fire is occurring on the
unit. Which of the following is priority action by the CN?
Answer: Instruct ambulatory clients to go to a safe area.
247. A nurse manager is completing a performance improvement audit and determines
documentation of clients discharge teaching is below the expected benchmark. Which of the
following actions should the nurse implement first?
Answer: Determine the factors that interfere with the documentation of clients' education.
248. A CN is conducting an in-service with staff members about infection control precautions.
The nurse should instruct the staff that which of the following clients requires droplet
precautions.
Answer: A client with pertussis.
249. A CN has been asked to determine staff adherence to established standards for post-op vital
sign measurement. Which of the following actions should the nurse take to collect information?
Answer: Conduct a retrospective chart audit of all surgical clients for the past 6 months.
250. A nurse manager is planning daily work and activities for the unit. Which of the following
actions is the nurse manager's priority?
Answer: Assign client care to staff.

251. A nurse in the Emergency Department is performing triage for a group of clients following a
motor-vehicle crash. Which of the following clients should the nurse request the provider assess
first?
Answer: A client who has arm contusions and manifest asymmetrical thoracic movement.
252. A nurse is teaching a newly licensed nurse about telephone prescription guidelines. Which
of the following statements by the newly licensed nurse indicates an understanding of the
teaching?
Answer: I should repeat the prescription back to the provider
253. A RN is working on the surgical unit when a client who has abdominal pain is admitted.
Which of following activities must be performed by the RN?
Answer: Completing the clients initial admission assessment.
254. A nurse is teaching a newly licensed nurse about incident reports. Which of the following
statements by the newly licensed nurse indicates an understanding of the teaching?
Answer: I should complete an incident report for an unexpected client occurrence.
255. A CN is managing conflict with a staff nurse who does not agree with the clients care
assignment. Which of the following statements is an example of using conflict resolution
strategy known as smoothing?
Answer: You always complete your work on time and do a great job. I believe you can handle
this assignment well.
256. A nurse is caring for a client who has an informed consent form for an upcoming procedure
in his health record. Which of the following actions should the nurse take to validate that the
client understands the procedure.
Answer: Ask the client to verbalize the purpose, risks, and benefits of the procedure.

257. A nurse is planning the discharge of a newborn who requires apnea monitoring at home. To
which of the following community agencies should the nurse anticipate referring to the guardian
of the newborn?
Answer: Home health
258. A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of
the following instructions should the nurse include?
Answer: Raise the footplates of the wheelchair before transferring the client.
259. A nurse on a quality improvement team is implementing a plan to decrease the rate of
pressure injuries in a long-term care facility. Which of the following actions should the team take
to evaluate the effectiveness of the plan?
Answer: Compare data from client's records regarding skin integrity with established criteria.
260. A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has
no orthopedic experience. Which of the following clients should be assigned to the medical
nurse?
Answer: a client who had the right above-the-knee amputation 24 hrs ago.
261. A nurse is caring for a client who is terminally ill and receiving nutritional support. The
client's adult children disagree about continuing nutritional support. The dilemma is referred to
the ethics committee. Which of the following actions should the nurse expect the committee to
take?
Answer: Assist in weighing the options involved in the decision.
262. A nurse manager is developing a class for newly licensed nurses on strategies to promote
client rights. Which of the following should the nurse manager include in the teaching?
Answer: Verify that the provider prescription is in the medical record for the clients who have
restraints.

263. A nurse manager is teaching confidentiality requirements to a staff. Which of the following
staff comments indicates an understanding of the teaching?
Answer: Change-of-shift report can be given at the client's bedside.
264. A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty.
Which of the following information can assist the nurse in evaluating the cost effectiveness of
the care?
Answer: The length of the client's stay.
265. A nurse is caring for a client who reports vomiting and diarrhea for the past 6hr. The nurse
should identify which of the following assessments is the priority?
Answer: Obtain the client's serum potassium level.
266. The AP tells a CN that it is unfair that they have to take care of all the clients who are
incontinent. Which of the following responses should the CN make?
Answer: I delegate tasks to personnel based on their job descriptions.
267. A client who has back pain presents to an emergency department and is provided a
prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is
seeking drugs and is not actually in distress. Which of the following responses should the CN
make?
Answer: Clients are the experts on their own pain.
268. A nurse is caring for a client who is scheduled for outpatient surgery. Which of the
following actions should the nurse take to verify the client gave informed consent?
Answer: Ask the client to explain the procedure that is being performed.
269. A nurse in the emergency department is admitting clients following an earthquake. The
emergency disaster plan has been implemented due to the anticipated arrival of a large number of
casualties. Which of the following clients should the nurse recommend the provider evaluate
first?

Answer: A client who has a sucking chest wound.
270. A charge nurse is supervising the care of several clients. Which of the following actions
requires intervention by the CN?
Answer: A nurse is photocopying their assigned client's diagnostic test results.
271. A CN is observing a newly licensed nurse's use of time-management skills. Which of the
following actions by the newly licensed nurse indicates effective use of the skill?
Answer: Group tasks that are in the same location.
272. A nurse is caring for a client who has terminal illness and voices concern about performing
selfcare after discharge. Which of the following statements should the nurse make?
Answer: Your case manager will coordinate the resources you will need.
273. A CN is leading a committee that is revising the policy for client discharge. After
developing the initial plan, which of the following actions should the nurse take next?
Answer: Determine the goals and objectives.
274. A nurse is caring for a client who requests pain medications. The nurse fulfills a promise to
return with the medications within 15min. The nurse is demonstrating which of the following
ethical principles?
Answer: Fidelity
275. A nurse is caring for a client who is 3-days post-op following open heart-surgery and will be
transferred to the medical-surgical unit. Which of the following information should the nurse
plan to include in the verbal report?
Answer: The clients LOC
276. A nurse receives notification of a fire on the unit. Which of the following should the nurse
take first?
Answer: Assist clients who are in immediate danger to a safe location.

277. A nurse is observing a newly licensed nurse perform a sterile dressing change on a client
who has a central venous catheter. Which of the following actions should the newly licensed
nurse take?
Answer: Pick up the first sterile glove by grasping the folded cuff edge.
278. A nurse is caring for a client who is hospitalized and has expressive aphasia. The client's
family reports that the nurse failed to obtain written informed consent before inserting an
indwelling urinary catheter. Which of the following responses should the nurse make?
Answer: This is a procedure that does not require a written informed consent.
279. A client is being discharged with a post-op infection, requiring daily home IV antibiotics
through a peripherally inserted central catheter (PICC) line. Which of the following actions
should the case manager perform prior to discharge?
Answer: Ensure that home infusion therapy has been arranged.
280. A nurse is speaking with the adult child who has severe Alzeimer's disease. The child is
crying and tells the nurse. “I don't know how much longer I can keep this up” Which of the
following responses should the nurse make?
Answer: Let's discuss options for respite care.
281. A nurse is caring for a client who is scheduled for rotator cuff surgery. The client tells the
nurse, “my shoulder doesn't hurt that bad. I want to wait for the surgery. Which of the following
responses should the nurse give?
Answer: I will notify your provider of your decision.
282. A nurse case manager is planning a teaching session on the use of critical pathways with a
group of newly licensed nurses. Which of the following information should the nurse include in
the teaching?
Answer: Critical pathways prevent unnecessary expense.

283. A charge nurse is discussing issues with a staff nurse. When evaluating statements by the
staff nurse, the charge nurse should recognize that which of the following reflects an
intrapersonal conflict?
Answer: I'm not sure whether I want to apply for the unit manager's position or start a family
this year.
284. A CN is orienting a newly licensed nurse to the facility's policies regarding electronic
medical records. Which of the following statements by the newly licensed nurse indicates an
understanding of the instructions?
Answer: After I finish with the printout of my assignments, I will put it in the shredder
receptacle.
285. A nurse manager sends home a nurse who is chemically impaired. Which of the following
actions should the nurse manager take?
Answer: Set up a formal meeting with the nurse within 24hr.
286. A nurse in a mental health facility is teaching a newly licensed nurse about the use of
mechanical restraints. Which of the following statements by the newly licensed nurse indicates
understanding of the teaching?
Answer: I should request the provider to examine the clients within 1-hour of applying the
mechanical restraints.
287. A nurse is caring for a group of clients on a unit. Which of the following assessment
findings should the nurse recognize as the priory to report to the charge nurse?
Answer: A client who is 2 days post-op and has a urine output of 20 ML/HR
288. A facility has identified an increase in health-care associated urinary tract infection (UTIs)
on the medical-surgical unity. A nurse is participating in a quality improvement process to
address this problem. Which of the following should be the first step in the process.
Answer: Establish best practice guidelines for reducing the incidence of UTIs.

289. A nurse is caring for a client who is comatose. The client has a living will that declines the
use of artificial enteral nutrition as a life-sustaining measure, but the client's family has requested
that the staff begin tube feeding. Which of the following actions should the nurse take?
Answer: Review the client's request with the family.
290. A CN is observing a newly licensed nurse care for a client who has a prescription for
application of an aquathermia pad to the right lower leg. Which of the following actions should
indicate to the charge nurse that the nurse understands how to use this device? Select all that
apply
Answer:
• Asks the clients to report it the aquathermia pad gets too warm
• Ensures that the client's call light is within reach
291. A nurse is caring for a client who has a potassium level of 3.2 mEq/K. The nurse has been
paging the provider for 1 hr to attempt to report the potassium level. Which of the following
actions should the nurse take next?
Answer: Notify the nursing supervisor
292. A nurse is caring for a client who has renal failure. The client tells the nurse that they have
decided to stop hemodialysis treatment. Which of the following actions should the nurse take to
act in the role of an advocate for this client?
Answer: Support the client's decision regarding treatment.
293. A nurse is teaching a newly licensed nurse about using electronic medical records. Which of
the following statements by the newly licensed nurse indicates an understanding of the teaching?
Answer: My access to the client electronic records might be tracked by my nurse manager.
294. A nurse is assessing a client who is post-op and has a PCA. The client exhibits restlessness,
an elevated pulse, and decrease in BP. Which of the following actions should the nurse take?
Answer: Place the client in a modified Trendelenburg position.

295. A CN is planning care for a group of clients. Which of the following tasks should be
delegated to an AP. Select all that apply
Answer:
• Ambulating
• Adding thickener to thin liquids
296. There has been a massive community disaster and stable clients must be discharged from a
facility to prepare for the influx of new casualties. A nurse should identify that which of the
following clients is safe to discharge?
Answer: A client who has multiple sclerosis and reports ataxia.
297. A nurse is reviewing the components of a surgical informed consent with a newly licensed
nurse. Which of the following statements should the nurse include?
Answer: The nurse should ensure the client understands the information given by the surgeon.
298. A nurse is presenting information on health care law to a group of newly licensed nurses.
Which of the following information should the nurse include?
Answer: The patient self-determination Act(PSDA) requires a nurse to give clients information
about end-of-life options
299. A charge nurse notices that a newly hired nurse consistently does not finish client care tasks
by the end of the shift. Which of the following statements should the charge nurse make?
Answer: you should set aside a time to plan your day at the beginning of each shift.
300. A nurse is caring for a group of clients on a medical-surgical unit. Which of the following
tasks should nurse delegate to AP?
Answer: Obtaining a stool specimen
301. A nurse is reinforcing teaching with an AP regarding body mechanics when moving a client.
Which of the following instructions should the nurse include in the teaching?
Answer: Maintain the client close to the body when transferring

302. A nurse is reinforcing teaching to a group of clients about coping. Which of the following
factors should the nurse identify as a situational factor that influences coping?
Answer: Physical handicap limited physical stamina
303. A nurse is collecting data on an adult client who has osteoporosis with kyphosis. Which of
the following manifestations should the nurse expect?
Answer: Pigeon chest appearance
304. Managing Client Care: Appropriate Assignment During Orientation
Answer: New RNs should be assigned a patient that they are competent caring for, and only
after their skills have been observed and approved by an experienced RN.
305. Airway Management: Discharge planning for a Client Who Has a Tracheostomy
Answer: Always have two extra trach tubes (one your size and one size smaller). Keep an
obturator for each trach tube and trach ties, Keep sterile saline and lubricant with you at all
times.
306. Professional Responsibilities: Responding to a Visitor's Question About Status of a Client
Answer: Information cannot be shared with unauthorized Individuals, Including family
members, unless they provide the code.
307. Professional Responsibilities: Teaching About Confidentiality
Answer: Client medical records must be kept in secure area, No information can be written on
public display boards. EMR should be password protected, and nurses must only use their own
log-in information. No part of the medical record can be copied, except for authorized exchange
of documents between health care institutions.
308. Preoperative Nursing Care: Securing Client Belongings
Answer: Give all pt belongings to family member to safely stored.

309. Managing Client Care: Prioritizing Client Care
Answer: Systemic before local: Acute befare chronic, Actual problems before potential
problems. Listen carefully to clients and don't assume.
Recognize and response to trends vs. transit findings. Recognize indications of medical
emergencies & complications vs expected find res. Apply clinical knowledge to procedural
standards to determine the priority action.
310. Professional Responsibilities: Adhering to Ethical Principles
Answer: Justice (fair treatment), beneficence ( doing good), nonmaleficence (doing no harm),
fidelity (faithfulness), autonom (independence], veracity (truthfulness)
311. Professional Responsibilities: Obtaining Informed Consent in an Emergency
Answer: Informed consent is not needed if the pt is unconscious and surgery is immediately
required to save their life.