2023 ATI Leadership Proctored Exam With Answers-194 Solved Questions

2023 ATI LEADERSHIP PROCTORED EXAM – REVISION
GUIDE(LATEST) 70 QUESTIONS AND ANSWERS WITH RATIONALE
QUESTIONS, ANSWERS AND RATIONALES.
1. 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 centre of the clients wound
C. Inflammation noted on the tissue edges of a client's wound
D. Increase in serosanguineous exudate from the clients' wound (damaged capillaries)
E. Inflammatory stage - beginning stage, also usually suggests infection
F. Begins with the injury and lasts 3 to 6 days
G. Effects to the wound: controlling bleeding with vasoconstriction and retraction of blood
vessels, and with clot formation. Delivering oxygen, WBCs, nutrients to the area via the
blood supply. Haemostasis occurs along with fibrin formation.
H. Macrophages engulf microorganisms and cellular debris (phagocytosis).
Answer: B. Deep red color on the centre of the clients wound
Rationale:
• Proliferative stage
• Lasts the next 3 to 24 days
• Effects to the wound: replacing lost tissue with connective or granulated tissue or collagen.
Contracting the wound’s edges. Resurfacing of new epithelial cells. Healthy granulation
tissue does not bleed easily. Dark granulation tissue can be a sign of infection, ischemia, or
poor perfusion. In the final phase of the proliferative stage of wound healing, epithelial cells
resurface the injury.
• Maturation or remodelling stage
• Occurs after day 21 and involves the strengthening of the collagen scar and restoration of a
more normal appearance. It can take more than 1 year to complete, depending on the extent
of the original wound. When scar tissues are forming.
• Appearance:
• Note the color of open wounds.

Red: healthy regeneration of tissue.
Yellow: the presence of purulent drainage and slough
Black: the presence of eschar that hinders healing and requires removal.
2. 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. - (fastacting insulin...usually takes effect after 15 minutes)
B. Administer pain medication to a 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.
Rationale:
• Fast-acting insulin takes effect within 15 minutes, so providing food is crucial to prevent
hypoglycemia. Ensuring the client has food available is a priority for their safety. While
administering pain medication (B) and restarting an infiltrated IV (C) are important, they are
not as immediately critical. Replacing the enteral feeding solution (D) also can wait, making
option A the top priority. (Fast-acting insulin...usually takes effect after 15 minutes)
3. 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 tumour and is admitted for chemotherapy
C. A client who has Guillain-Barre syndrome and a tracheostomy -unstable
D. A client who sustained a concussion and is being monitored for complication
Answer: A. A client who has multiple sclerosis and ataxia
Rationale:
Normal finding for someone that has multiple sclerosis = most stable - showed up on online
practice tests.
• Dead
• Unstable

4. 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 a serious health problems to sign my advance directives”
C. “My doctor will need to provide approval for the decisions outlines in my living will
D. “My durable power of attorney for health care is part of my advance directives”
Answer: D. “My durable power of attorney for health care is part of my advance directives”
Rationale:
• Leadership 7.0 page 38
• Durable power of will and living will are components of advance directives.
• This statement indicates an understanding that advance directives encompass various
documents, including a durable power of attorney for healthcare, which designates someone
to make medical decisions on the client's behalf. The other options reflect misunderstandings:
A living will does not require a co-signer (A), advance directives should ideally be completed
before serious health issues arise (B), and a doctor’s approval is not needed for the directives
themselves (C). Thus, option D accurately reflects the purpose and components of advance
directives.
5. 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. Evaluate the 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
Rationale:
This step is essential as it establishes a foundational understanding of best practices and
guidelines that the new birth care center should follow. Knowing the industry standards will
inform the selection, evaluation, and measurement of any safety systems implemented.
Without a clear grasp of these standards, subsequent steps (B, C, and D) may lack direction
and effectiveness. Therefore, identifying industry standards should be the first task assigned.

6. 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
Rationale:
A speech therapist specializes in evaluating and treating swallowing disorders, known as
dysphagia. The client's frequent coughing during meals and only eating half of the food may
indicate difficulty swallowing, necessitating further assessment. Referring to a speech
therapist can help identify the underlying issues and provide appropriate interventions. Other
therapists, such as physical or occupational therapists, focus on different aspects of care and
are not specialized in swallowing difficulties.
7. 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 (select all that apply)
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 vinyl flooring in the kitchen
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 vinyl flooring in the kitchen
D. A folding chair without arm rests.
Rationale:
• The wheeled office chair can move unexpectedly, posing a fall risk, especially for a client
with a history of falls.
• A throw rug can create a tripping hazard, especially if it covers cracked flooring.
• A folding chair without arm rests may provide insufficient support when sitting down or
standing up, increasing the risk of falls.

• B (raised toilet seat) and E (two-wheeled walker) are generally considered fall-prevention
aids rather than risks.
8. 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 reports
pruritus
D. An adolescent who is newly diagnosed with DM and requires teaching regarding insulin
Administration
Answer: B. A middle adult client who has a below the knee amputation and requires a
dressing change
Rationale:
• Stable; only needs dressing change
• The appropriate client for assignment to a Licensed Practical Nurse (LPN) is B. A middle
adult client who has a below the knee amputation and requires a dressing change. LPNs are
trained to perform basic nursing tasks, including wound care and dressing changes, which are
within their scope of practice. This task is stable and does not require the advanced critical
thinking or assessment skills needed for the other clients. In contrast, options A, C, and D
involve complex assessments or require patient education and management of potentially
unstable conditions, making them more appropriate for a Registered Nurse (RN).

9. 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 processB. 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

Rationale:
This step addresses the systemic issue of missing documentation and ensures that all nurses
understand the importance of advance directives as part of the admission process. It allows
for an open discussion on the policy, clarifying responsibilities and reinforcing compliance to
prevent future omissions. While reminding nurses or asking specific ones to obtain missing
information is important, a collective review promotes consistency and accountability across
the unit.
10. 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 his a fever.
B. A client whose pressure ulcer has serosanguineous drainage on the dressing-normal
C. A client who has diabetes mellitus and is diaphoretic- hypoglycemia
D. A client who has a fractured hip and reports a pain level of 7 on a scale from 0 to 10.-no
Answer: A. A client who is postoperative and his a fever.
Rationale:
• Hypoglycemia may lead to SZ, coma or death if it’s not treated right away. Other S/S:
Tachycardia, cold sweats, irritability, confusion, and diaphoretic aka sweating.
• This client is experiencing signs of hypoglycemia, which is a critical and potentially lifethreatening condition that requires immediate intervention to prevent further complications,
such as loss of consciousness or seizures. While the postoperative fever, pressure ulcer
drainage, and hip fracture pain are important, they do not pose an immediate risk to life like
hypoglycemia does. Rapid assessment and treatment of the hypoglycemic client are essential
for their safety.
11. A nurse is receiving change-of-shift report for four clients. Which of the following clients
should the nurse care for first?
A. A client who is 4 hr post-operative 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 diarrhea
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 post-operative following a hernia repair and has pitting
edema of the right leg
Rationale:

Pitting edema in a postoperative client can indicate potential complications, such as venous
thromboembolism or impaired circulation, which require immediate assessment and
intervention. Prompt evaluation is critical to prevent further complications. While the other
clients have important needs, they do not present the same level of urgency as the
postoperative client with edema, making this the priority.
12. 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
Rationale:
This action is crucial to understanding the specifics of the conflict, including its root causes
and the perspectives of both day and night shift nurses. Without a clear understanding of the
issues at hand, any further steps may be ineffective. Gathering information allows the
manager to address the conflict more constructively and develop an informed strategy for
resolution. Acknowledging the conflict or encouraging resolution without this context may
lead to miscommunication and unresolved issues.
13. 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 - protect yourself first
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 - protect yourself first
Rationale:
Protecting oneself is crucial before attending to the client to prevent further contamination
and ensure the nurse's safety. Once adequately protected, the nurse can then proceed to assess
and treat the client effectively. While irrigation and clothing removal are essential steps in
managing chemical exposure, the nurse's safety must come first to avoid any risk of harm to

themselves. Reporting to OSHA is also important but is not an immediate action in the
context of providing care.
14. 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: B. Measure the client’s vital signs
Rationale:
Ensuring the safety and stability of the client who received the wrong medication is the top
priority. Monitoring vital signs helps assess for any immediate adverse effects of metoprolol,
such as bradycardia or hypotension. After ensuring the client's safety, the nurse can then
proceed to inform the nurse manager, call the provider, and complete an incident report.
Addressing the client's condition is essential before any administrative actions.
15. 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. A generalized rash over trunk
C. Increased temperature
D. Report of photophobia
Answer: A. Decreased level of consciousness
Rationale:
• Getting sleepier…neurological damage? Maybe? INC ICP
• Seek immediate medical care if you or someone in your family has meningitis symptoms,
such as:
• Fever.
• Severe, unrelenting headache.
• Confusion.
• Vomiting.
• Stiff neck.

16. 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. Blood culture was obtained after antibiotic therapy had been initiated c.
C. A penicillin allergy required an alternative antibiotic to be prescribed HMM
D. The route of antibiotic therapy on the care pathway was changed from IV to PO
Answer: B. Blood culture was obtained after antibiotic therapy had been initiated c.
Rationale:
• A variance report should be initiated whenever an error is made involving a client, even if
no injury occurred.
• According to standard protocols, blood cultures should be obtained before starting
antibiotics to ensure accurate identification of the infectious organism. Initiating antibiotics
prior to obtaining cultures can compromise the effectiveness of the cultures and affect
treatment decisions. While the other options involve variations from the care pathway, they
do not indicate a breach of critical safety protocols like option B does.
17. 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 medicalsurgical 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. - most stable
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. - most stable
Rationale:
This client is relatively stable and requires assistance with mobility, which is a task that a
medical-surgical nurse is well-equipped to handle. The other clients have more complex
needs: option A involves medication management and monitoring, option B requires
specialized education in breastfeeding, and option D involves managing a critical medication
like magnesium sulfate, which requires specific knowledge of maternal-newborn care.

18. 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
Rationale:
This team member specializes in preventing and controlling infections within healthcare
settings and has expertise in MRSA transmission dynamics and effective strategies to reduce
its spread. The infection control nurse can provide valuable insights on best practices,
surveillance methods, and protocols specific to MRSA. While the other options, such as the
risk management coordinator and clinical pharmacist, may contribute to the discussion, the
infection control nurse is the most directly relevant expert for addressing the proposed
standards related to MRSA transmission.
19. 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 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 consultation to determine the client’s reasons for refusing surgery
Answer: A. Discuss with the client her concerns regarding the procedure
Rationale:
This approach allows the nurse to understand the client’s feelings and reservations about the
recommended surgery, fostering a supportive and therapeutic relationship. By actively
listening, the nurse can address specific fears or misconceptions the client may have. While
providing information or discussing consequences is important, addressing the client’s
concerns first helps ensure that any further education or options presented are tailored to her
needs and anxieties.

20. 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
Rationale:
In emergency situations where a client is unconscious and requires immediate surgery to save
their life or prevent serious harm, the legal principle of implied consent applies. This allows
medical professionals to proceed with necessary interventions when obtaining informed
consent is not feasible. Delaying the surgery for consent could jeopardize the client's health,
while other options, such as obtaining telephone consent or asking the anaesthesiologist to
sign, are not appropriate in this urgent context.
21. A nurse is planning to delegate client care assignments. 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
Rationale:
This task is within the scope of practice for assistive personnel, as it involves following
specific protocols for postmortem care and does not require advanced clinical judgment or
assessment skills. The other tasks—advising on medication, teaching self-administration of
blood glucose testing, and informing the family about progress—require nursing knowledge,
critical thinking, and direct patient assessment, making them inappropriate for delegation to
assistive personnel.
22. A nurse is working on a quality improvement team that is assessing an increase in client
falls 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 for falls
Answer: D. Identify clients who are at risk for falls
Rationale:
This step is crucial for understanding the specific factors contributing to the increased fall
rates and allows the team to target interventions effectively. By assessing at-risk clients, the
team can gather data necessary for formulating a tailored fall prevention plan. While
notifying staff and reviewing literature are important, these actions come after the
identification of at-risk clients. Implementing a fall prevention plan should be based on the
findings from this initial assessment.
23. A nurse is completing a 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 a protective environment.
D. The AP wears a mask when caring for a client who has varicella
Answer: A. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium
difficile
Rationale:
• Alcohol-based hand sanitizers are highly effective against non–spore-forming organisms,
but they do not kill C. difficile spores or remove C. difficile from the hands
• This is inappropriate because alcohol-based hand sanitizers are not effective against C.
difficile spores; handwashing with soap and water is required to remove the spores
effectively. The other actions—closing the door for airborne precautions, removing cut
flowers from a protective environment, and wearing a mask for varicella—are appropriate
and adhere to infection control protocols. Correcting the AP's misunderstanding about hand
hygiene is essential for preventing the spread of infections.
24. A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps
for medication administration. Which of the following is the priority action by the charge
nurse?

A. Asses the staff nurses’ knowledge deficit - assess first
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. Asses the staff nurses’ knowledge deficit - assess first
Rationale:
This step is essential to determine the specific areas where the nurses are struggling with the
new IV infusion pumps. By identifying the knowledge gaps, the charge nurse can tailor
subsequent interventions effectively, whether it involves pairing nurses, demonstrating the
pump, or planning an in-service education program. Understanding the root cause of the
difficulty ensures that the support provided is relevant and addresses the actual needs of the
staff, ultimately improving patient safety and care.
25. 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 an NG tube
B. Check a client’s pain level 30 min after receiving acetaminophen
C. Collect a urine specimen from a newly admitted client
D. Instruct a client to splint an abdominal incision
Answer: C. Collect a urine specimen from a newly admitted client
Rationale:
This task is appropriate because it is a straightforward procedure that does not require
advanced nursing skills or clinical judgment. The other options—administering feeding via
an NG tube, checking pain levels, and instructing a client on splinting an incision—require
nursing knowledge, assessment, and patient education, making them unsuitable for delegation
to an AP. Assigning tasks within the AP's scope of practice ensures efficient teamwork and
optimal patient care.
26. 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 BLACK

Answer: B. Provide treatment for life-threatening injuries
Rationale:
• Red tags - (immediate) are used to label those who cannot survive without immediate
treatment but who have a chance of survival.
• Yellow tags - (observation) for those who require observation (and possible later re-triage).
Their condition is stable for the moment and, they are not in immediate danger of death.
These victims will still need hospital care and would be treated immediately under normal
circumstances.
• Green tags - (wait) are reserved for the "walking wounded" who will need medical care at
some point after more critical injuries have been treated.
White tags - (dismiss) are given to those with minor injuries for whom a doctor's care is not
required.
• Black tags - (expectant) are used for the deceased and for those whose injuries are so
extensive that they will not be able to survive given the available care.
27. 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 tacks to secure the carpet on the stairs X
B. The client’s electrical cord is taped to the floor X
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 X
Answer: C. The client's bedside lamp is plugged in using an extension cord with two prongs
Rationale:
This situation poses a risk because two-prong extension cords do not provide grounding,
increasing the likelihood of electrical shock, especially if the lamp is used near water. While
the other findings (tacks on stairs, taped electrical cords, and cleaning supplies stored above
head) also present safety concerns, the use of an ungrounded extension cord directly impacts
electrical safety and requires immediate attention. Addressing this hazard is crucial to
ensuring the client's safety in their home environment.
28. 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

B. Removes fresh flowers from the client’s room.
C. Washes her hands with an alcohol-based hand rub after caring for the client.
D. Wears a gown when caring for the client
Answer: D. Wears a gown when caring for the client
Rationale:
• C-diff is considered Contact Isolation
• Gowns are necessary when caring for clients with Clostridium difficile infections to prevent
the spread of spores that can contaminate clothing. The other options are not appropriate:
applying a mask is not required for C. difficile, fresh flowers should be removed to minimize
infection risk, and alcohol-based hand rubs are ineffective against C. difficile spores—
handwashing with soap and water is required instead. Thus, wearing a gown is the correct
practice for infection control in this scenario.
29. 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? (Select all that apply.)
A. Pipe cleaners
B. O2 Tank
C. Cotton balls
D. Petroleum Jelly
E. Obturator
Answer: A. Pipe cleaners
B. O2 Tank
E. Obturator
Rationale:
• Pipe cleaners can be useful for cleaning the inner cannula of the tracheostomy tube.
• An O2 tank may be necessary if the client requires supplemental oxygen, especially if they
have respiratory issues.
• The obturator is important for the safe insertion of the tracheostomy tube in case it needs to
be replaced.
30. 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
Rationale:
• The form for informed consent must be signed by a competent adult. Emancipated minors
(minors who are independent of their parents, such as a married minor) can provide informed
consent for themselves.
• It typically lacks the cognitive capacity to understand the implications of the procedure and
therefore cannot provide informed consent.
31. 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 anaesthetic:
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: A. “I can wear my ankle bracelet since i am just having a local anaesthetic:
B. “I can leave my wedding ring on if it is taped in place”
Rationale:
• Regardless of the type of anaesthesia, jewellery and accessories should typically be
removed to prevent interference during surgery and reduce the risk of burns or injury.
• Taping a wedding ring does not eliminate the risk of complications; it is generally safer to
remove all jewellery to prevent damage or complications during the surgical procedure.
• Removing dentures before surgery is standard practice to prevent aspiration risks, and D.
leaving valuables with a family member is a safe option to protect personal items.
32. 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
Rationale:
Requesting a consultation after trying treatments (A) may delay necessary care, while having
the consultant see the client daily (B) is impractical. Providing subjective opinions (D) can
hinder effective assessment and planning.
33. 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 - ok
C. Points tubing in the direction of the umbilicus during insertion - ok
D. Inserts the tubing 8cm (3.1 in) into the rectum -ok insert 3-4 inches
Answer: A. Positions the client on her left side with knees flexed
Rationale:
• Sims position: left side, right leg flexed, left leg straight
• The other actions—administering the solution at room temperature (B), pointing the tubing
toward the umbilicus during insertion (C), and inserting the tubing 8 cm (3.1 in) into the
rectum (D)—are all appropriate practices. However, the correct positioning should prioritize
flexed knees to maximize the effectiveness of the procedure.
34. 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.”
Rationale:
• Encryption is a way to make data unreadable at rest and during transmission.

Encrypting information protects it from unauthorized access, aligning with confidentiality
standards.
• The other statements reflect a lack of understanding: B is incorrect as posting vital signs
publicly violates privacy, C is inappropriate because using another nurse's password is a
breach of security, and D is wrong since personal health information should be shredded, not
discarded in the trash. Thus, statement A demonstrates the newly licensed nurse's
comprehension of confidentiality practices.
35. 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?
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
Rationale:
• Showed up on practice tests
• While the ANA Standards of Practice (A) and ANA Code of Ethics (B) provide important
guidelines on nursing practice and ethical considerations, they do not specify legal
parameters. The Institute of Medicine (D) offers valuable insights into healthcare but is less
relevant for establishing specific nursing policies related to scope of practice. Thus, the state
nurse practice act is the most critical resource for this policy planning.
36. 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
Rationale:
• Review ATI pg. 47

• Autonomy: The ability of the client to make personal decisions, even when those decisions
might not be in the client’s own best interest
• Beneficence: Care that is in the best interest of the client
• Fidelity: Keeping one’s promise to the client about care that was offered
• Justice: Fair treatment in matters related to physical and psychosocial care and use of
resources
• Nonmaleficence: The nurse’s obligation to avoid causing harm to the client
• Veracity: The nurse’s duty to tell the truth
37. 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
B. Establish work initiatives to promote a positive environment
C. Compare practices within the facility against other high-performing facilities
D. Determine how current practice will affect future performance within the facility
Answer: C. Compare practices within the facility against other high-performing facilities
Rationale:
• Benchmarks are goals that are set to determine at what level the outcome indicators should
be met.
• Data is collected, analyzed, and compared with the established benchmark.
• If the benchmark is not met, possible influencing factors are determined. A root cause
analysis can be done to critically assess all factors that influence the issue. A root cause
analysis:
• Focuses on variables that surround the consequence of an action or occurrence.
• Is commonly done for sentinel events (client death, client care resulting in serious physical
injury) but can also be done as part of the quality improvement process.
• Investigates the consequence and possible causes.
• Analyzes the possible causes and relationships that can exist.
• Determines additional influences at each level of relationship.
• Determines the root cause or causes.
38. 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. Auscultate the client’s lungs
Rationale:
Ensuring the client's immediate safety and health is the priority. After assessing the lungs, the
nurse can then proceed to place a faulty equipment tag on the pump (A), notify the provider
(B), and complete an incident report (D) as necessary. Addressing the client’s condition
comes first before any administrative actions.
39. 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”
Rationale:
• This statement acknowledges the client’s feelings and provides an opportunity for her to
reconsider her decision, emphasizing that her autonomy is respected.
• The other options are less appropriate: B may come off as judgmental, C minimizes the
client’s feelings, and D could invalidate her concerns by suggesting she shouldn't feel
worried. By offering the option to cancel, the nurse fosters an open dialogue and supports the
client’s emotional needs during a vulnerable moment.
40. 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. Methicillin-resistant Staphylococcus aureus
Answer: A. Lyme disease
Rationale:

• Lyme disease is a notifiable infectious disease, and reporting it helps public health officials
track outbreaks and implement control measures.
• The other infections—B. Bacterial conjunctivitis, C. Health care-acquired pneumonia, and
D. Methicillin-resistant Staphylococcus aureus—while important for infection control within
healthcare settings, are typically not required to be reported to public health authorities unless
they meet specific criteria for outbreak investigation. Reporting Lyme disease is crucial for
monitoring its spread and ensuring public safety.
41. 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 - orders included in paperwork transferred
with patient to facility
B. The client’s preferred time for bathing - who you think you is
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 - the only relevant
information at the time of transfer - also showed up on practice tests
Answer: D. The time the client received his last dose of pain medication - the only relevant
information at the time of transfer - also showed up on practice tests
Rationale:
The other options are less relevant for the transfer report: A provides procedural details better
suited for written documentation, B is personal preference and not critical for immediate care,
and C discusses family dynamics that may not impact the client's immediate medical needs.
Thus, focusing on the last pain medication dose ensures the receiving team has essential
information for ongoing care.
42. 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. Ensure that the provider signs the prescription
Answer: B. Read back the prescription to the provider
Rationale:

• This action ensures accuracy and helps to verify that the prescription was understood
correctly, reducing the risk of errors.
• Once the prescription is confirmed, the nurse can then proceed to write it down (A),
document it in the medical record (C), and ensure the provider signs it later (D). However,
verifying the prescription with the provider is the most critical initial step to ensure patient
safety.
43. 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
Rationale:
Addressing the issue directly with the assistive personnel (AP) allows for immediate
feedback and clarification of the proper protocols. It’s important to ensure that the AP
understands the importance of following facility procedures for safety and infection control.
After discussing it with the AP, the nurse can consider other actions if necessary.
44. 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 - never raise all 4 side rails up - considered a
restraint
B. Remove the clock and calendar from the client’s room→ reorient client
C. Obtain a prescription for a sedative for the client→ chemical sedations. less invasive first;
meds always last resort and if patient is causing harm to him/herself only
D. Provide distractions for the client during the day
Answer: D. Provide distractions for the client during the day
Rationale:
Offering engaging activities can help reduce wandering and keep the client occupied,
promoting a sense of security and reducing anxiety. This approach is less restrictive and more
supportive than the other options.

45. 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 → Chlamydia is an STI...Sexually Transmitted ← maybe they
tryna have sex with gloves and gown hahah
B. Report the infection to the local health department - nationally reportable
C. Apply an antiviral cream to lesions - Topical antibiotic therapy alone is inadequate for the
treatment of chlamydial infection and unnecessary when systemic treatment is administered.
D. Instruct the client to use condoms until the treatment is completed → avoid sex while
undergoing treatment ooi
Answer: B. Report the infection to the local health department - nationally reportable
Rationale:
Chlamydia is a nationally reportable disease, and reporting it helps in tracking and managing
public health concerns. The other options, while important in the context of managing the
infection, do not address the legal and public health requirement to report the diagnosis.
46. 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
Rationale:
• Steps of Evidence-Based Practice
• Converting the need for information (about prevention, diagnosis, prognosis, therapy,
causation, etc) into an answerable question
• Tracking down the best evidence with which to answer that
• Critically appraising that evidence for its validity (closeness to the truth), impact (size of the
effect), and applicability (usefulness in our clinical practice)
• Integrating the critical appraisal with our clinical expertise and with our patient's unique
biology, values and circumstances
Evaluate:
• Evaluating our effectiveness and efficiency in executing Steps 1-4 and seeking ways to
improve them both for next time

47. 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-clean skin with water
D. Admit the injured clients to positive-pressure rooms
Answer: B. Remove contaminated clothing
Rationale:
• p.102 undress the client and remove all identifiable particulate matter
• This action helps to prevent further absorption of harmful chemicals and reduces the risk of
contamination spreading to others. The other options are inappropriate: A placing shower
caps does not address contamination effectively, C scrubbing the skin with betadine is not
recommended; instead, the skin should be rinsed with water, and D admitting clients to
positive-pressure rooms is unsuitable, as contaminated individuals should be decontaminated
in a controlled environment before admission. Therefore, removing contaminated clothing is
the priority to ensure safety and effective triage.
48. 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
Rationale:
• False communication or communication with careless disregard for the truth with the intent
to injure an individual’s reputation.
• Libel: Defamation with the written word or photographs (a nurse documents in a client’s
health record that a provider is incompetent).
• Slander: Defamation with the spoken word (a nurse tells a coworker that she believes a
client has been unfaithful to the spouse).

49. 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 normal
capacity between 400-600. 1st need to void at 150mL, urge to void at 300. OK
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
Rationale:
• Patient may complain of nausea if tube is not patent...
• Nausea in this context may indicate a potential complication, such as gastric distension or
an obstruction, requiring immediate evaluation to prevent further issues. While the other
clients also need attention, A is stable, B shows expected drainage post-surgery, and C has an
elevated glucose level that, while concerning, is not an immediate threat. Therefore,
addressing the client with nausea is the priority to ensure their safety and well-being.
50. 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 HIPPA 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: A. “Please stop discussing the client in a public area”
Rationale:
• This statement directly addresses the breach of confidentiality and emphasizes the
importance of maintaining client privacy in a clear and immediate manner. The other options
are less effective: B questions the nurse's understanding without addressing the behavior, C
shifts the focus away from the confidentiality issue, and D escalates the situation
unnecessarily without first addressing the immediate concern. By asking the nurse to stop the
discussion, the charge nurse takes a proactive stance to protect client confidentiality.

51. 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 30min 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
Rationale:
Using sterile forceps ensures that the gauze does not come into contact with non-sterile
surfaces, preserving the sterility of the dressing. The other options do not maintain sterility: A
placing gauze too close to the edge of a sterile drape risks contamination, C setting up the
sterile field 30 minutes in advance can lead to contamination, and D using a gloved hand to
adjust a gown is improper, as the outside of the gown is considered non-sterile. Therefore,
using sterile forceps is the only action that correctly upholds sterile technique.
52. 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
Rationale:
• Could be C. diff due to the regular use of antibiotics - kills normal flora - chronic use of
antibiotics can lead to it.
• Frequent loose stools in a client receiving antibiotics may indicate a risk for Clostridium
difficile infection, which can survive on surfaces and requires thorough cleaning with bleach
to ensure proper disinfection. The other options are not appropriate: A placing the client in a
negative-pressure room is unnecessary for gastrointestinal infections, B while hand hygiene is
crucial, alcohol-based sanitizer is not effective against C. difficile spores; soap and water are
preferred, and D droplet precautions are not indicated for gastrointestinal infections. Thus,
cleaning with bleach is the most appropriate action.

53. 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 take a break.
D. Ask other a staff members to take over some of his tasks.
Answer: B. Recommend that he take time to plan at the beginning of his shifts.
Rationale:
This strategy allows the newly licensed nurse to prioritize tasks, set realistic goals, and
organize his workload, which can enhance focus and efficiency throughout the shift. The
other options may not effectively address the underlying issue: A advising to complete easier
tasks first could lead to disorganization, C offering to provide care may enable dependency,
and D asking other staff to take over can create a burden on colleagues and does not foster
independence. Planning is a crucial skill for time management and effective nursing care.
54. 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?
A. The client needs to have someone bring O2 tanks and equipment to her home. - case
manager?
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 bathe at home.
Answer: C. The client needs to arrange financial resources to purchase equipment.
Rationale:
Social workers can assist clients with financial assessments and connect them to resources or
programs that may help cover the costs of necessary medical equipment. The other options do
not specifically require a social worker’s expertise: A regarding O2 tanks may involve a case
manager or home health nurse, B concerning range-of-motion exercises relates more to
physical therapy, and D about bathing assistance can be addressed by home health services
rather than a social worker. Thus, financial resource planning is the key reason for the
referral.

55. 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 requires assistance with completing oral hygiene.
Rationale:
• Occupation Therapist promotes or improves a person’s ability to do ADL’s
• Occupational therapists help clients develop or regain skills needed for daily activities,
including personal care tasks like oral hygiene, especially in conditions like rheumatoid
arthritis that may impair hand function. The other options do not directly relate to
occupational therapy: A pertains to eating and may require a speech therapist, B about joining
a support group is more about emotional support rather than therapy, and D regarding
ambulation is typically within the scope of physical therapy. Thus, assistance with oral
hygiene is the primary reason for the referral to an occupational therapist.
56. 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 therapists
B. Case Manager
C. Mental Health counsellor
D. Occupational therapist
E. Physical therapist
Answer: A. Nutritional therapists
B. Case Manager
C. Mental Health counsellor
Rationale:
Nutritional therapists help develop meal plans to address the client’s dietary needs and
promote healthy weight gain. The case manager coordinates resources and support services
for comprehensive care. Mental health counsellors provide therapy to address psychological
issues related to the eating disorder. Occupational and physical therapists are less relevant in

this context, as they focus more on physical function than on nutritional and psychological
aspects.
57. A nurse is prioritizing care after a receiving change-of-shift report on a four clients.
Which of the 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
Rationale:
• Pg 6 Third: Circulation. Identify circulation concern (hypotension, dysrhythmia, inadequate
cardiac output, compartment syndrome).
• Heart attack
• This combination of symptoms can be indicative of a cardiac event, especially in women,
where atypical presentations like jaw pain may signal an underlying issue. The other clients,
while they have concerning symptoms, are less immediately life-threatening: A (headache
with light sensitivity) could indicate migraines or meningitis, B (light headed ness upon
standing) may suggest orthostatic hypotension, and D (urge to void without urination) could
relate to urinary retention. Thus, the potential severity of the jaw pain and indigestion makes
it the priority for assessment.
58. 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 a 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
Rationale:
• Pg 77 (mental ATI) Complication: Physical exhaustion and possible death: A client in a true
manic state usually will not stop moving, and does not eat, drink, or sleep. This can become a
medical emergency.

• This behavior may indicate heightened agitation or mania, which can lead to increased risk
for self-harm or aggression toward others. While A (depressive disorder with poor hygiene),
B (dementia with aphasia), and D (schizophrenia with neologisms) present their own
concerns, they do not pose the immediate risks associated with the pacing client. The pacing
could suggest a lack of impulse control or distress that requires urgent assessment and
intervention to ensure the client's safety and stability.
59. 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 a bowel movement after taking a
laxative 12hr ago.
C. Provide instruction to the caregiver of a client who has dementia and a 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.
Rationale:
This situation raises concerns for complications such as compartment syndrome or issues
related to circulation, which require immediate assessment and intervention. While A
(obtaining a breakfast tray) and C (providing instructions to a caregiver) are important, they
do not present an urgent safety risk. B (auscultating bowel sounds) is relevant but less critical
compared to the potential severity of new pain in a casted limb. Therefore, prioritizing the
assessment of the client with the leg cast is crucial for timely intervention.
60. 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.”
Rationale:

• A durable power of attorney for health care/health care proxy is a legal document that
designates a health care surrogate, who is an individual authorized to make healthcare
decisions for a client who is unable.
• This statement accurately explains the role of a health care proxy, emphasizing their
authority to make medical decisions on behalf of the client during times of incapacity. The
other options provide misleading or incomplete information: A incorrectly suggests only
family members can be chosen, C implies a time constraint that may not be necessary, and D
states that attorney approval is needed, which is not typically required. Clear and accurate
information about advance directives is essential for empowering clients in their healthcare
decisions.
61. 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.
Rationale:
This step is essential to verify that the medications are correctly prescribed and ensure that
there are no discrepancies or errors. Once this verification is complete, the nurse can then
address the client's concerns about the medications. While C (reviewing the medication's
purpose) and D (calling the provider) are also important, they should come after confirming
that the medications were appropriately ordered. Ensuring accuracy in medication orders is
critical to patient safety.
62. 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 38C (101F)
Answer: C. A client who has peripheral vascular disease and has an absent pedal pulse in the
right foot
Rationale:
This finding indicates a potential acute vascular compromise, which could lead to tissue
ischemia or necrosis if not addressed promptly. While the other clients also have significant
issues, the absence of a pulse is a critical sign that requires immediate assessment and
intervention to prevent serious complications. In contrast, the other conditions, while
concerning, do not pose an immediate life-threatening risk. Prioritizing interventions based
on severity and potential for deterioration is essential in nursing care.
63. 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. its not transmitted person to
person, not droplet or airborne
Answer: C. Prepare to administer antibiotics to the client.
Rationale:
To prepare to administer antibiotics to the client. Cutaneous anthrax is primarily treated with
appropriate antibiotics, such as ciprofloxacin or doxycycline, to prevent further complications
and systemic infection. While other precautions may be necessary in a broader context,
cutaneous anthrax is not transmitted from person to person, so wearing an N95 respirator is
not required. The primary focus should be on timely antibiotic administration to ensure
effective treatment. Additionally, placing a surgical mask on the client is unnecessary since
the disease is not airborne.
64. 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 not taking scheduled breaks.
Answer: D. Determine the reasons the nurses are not taking scheduled breaks.
Rationale:
To determine the reasons the nurses are not taking scheduled breaks. Understanding the
underlying issues is crucial before addressing the situation. By assessing the reasons, the
charge nurse can identify if there are systemic problems, workload concerns, or personal
preferences affecting the nurses’ ability to take breaks. This information will inform
subsequent actions, such as providing support or revising staffing strategies, to ensure that all
staff can take their breaks while maintaining patient care standards.
65. 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
Rationale:
Battery refers to the intentional and unauthorized physical contact with another person. In this
scenario, the nurse administered an injection without the client's consent, which constitutes a
violation of the client's rights. Even if the nurse's intention was to alleviate pain,
administering medication against the client's wishes disregards their autonomy and right to
make informed decisions about their treatment. Such actions can lead to legal consequences
for the nurse and damage the trust in the nurse-client relationship.
66. A nurse is speaking with a visitor who asks a questions 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.”
Rationale:
This response maintains the client's confidentiality and adheres to HIPAA regulations, which
protect patient privacy. It is essential for nurses to respect the privacy of clients and refrain
from disclosing any information without explicit consent. The nurse's response also directs
the visitor to communicate directly with the client, promoting respect for the patient's
autonomy. This approach fosters trust while ensuring compliance with legal and ethical
standards in healthcare.
67. 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
Rationale:
Respite care provides temporary relief for caregivers, allowing them to rest and recharge.
This is crucial for partners of clients with cognitive impairments, as caregiving can be
physically and emotionally demanding. By taking time off, the caregiver can manage stress,
prevent burnout, and maintain their own well-being, ultimately improving the quality of care
they provide. This support enables caregivers to return to their responsibilities refreshed and
better equipped to handle challenges.

68. 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
Rationale:
This principle emphasizes the importance of truthfulness and honesty in nursing practice. In
this situation, the charge nurse has an ethical obligation to accurately report the incident,
including the absence of the gait belt, to ensure transparency and accountability. By being
truthful in the incident report, the nurse not only upholds professional integrity but also
contributes to improving safety protocols and preventing future falls. Veracity is essential for
maintaining trust between healthcare providers and clients, as well as within the healthcare
team.
69. 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.
Rationale:
Informed consent requires that the client fully understands the procedure, including its risks
and benefits, before agreeing to it. The nurse's role includes evaluating the client's
comprehension of the information provided by the healthcare provider. By assessing the
client's understanding, the nurse ensures that the client can make an informed decision
regarding their care. This step is crucial for confirming that the consent is valid and that the
client feels confident about the procedure. While reviewing risks and alternatives may be
important, it is primarily the provider's responsibility to discuss those aspects.
70. 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?
A. Remove the client’s restraints every 2 hr.
B. Allow 1 fingerbreadth between the restraint and the client’s wrists Dos!
C. Attach the restraints to the fixed portion of the frame of the client’s bed. Moveable part!
D. Secure the client’s restrains with a square knot. Quick release knot batch

Answer: A. Remove the client’s restraints every 2 hr.
Rationale:
This practice is essential for ensuring the client’s comfort and to assess for any potential
complications, such as skin breakdown or circulation issues. Regularly removing restraints
allows for range-of-motion exercises and provides an opportunity to evaluate the need for
continued use. This aligns with best practices for restraint use, which emphasize client safety
and dignity. It's also important to monitor the client's physical and emotional state during the
assessment. Proper training on restraint application and monitoring is crucial for assistive
personnel to ensure patient safety.
MORE REVISION
71. A nurse is preparing an educational program for staff members 2 a new intravenous
pump. Identify the sequence of actions the nurse should taken when developing the program.
(Move the steps into the box on the right, placing them in order of performance).
A. Determine what skills to teach the staff members.
B. Develop learning objectives for the program.
C. Identify resources available to meet objectives.
D. Review the staff member's’ evaluation of the program.
Answer: A. Determine what skills to teach the staff members.
B. Develop learning objectives for the program.
C. Identify resources available to meet objectives.
D. Review the staff member's’ evaluation of the program.
Rationale:
• This step is crucial as it identifies the specific knowledge and competencies that need to be
addressed in the educational program.
• After identifying the skills, the nurse should formulate clear, measurable objectives that
align with the identified needs of the staff.
• Once objectives are established, the nurse can gather necessary materials, tools, and
references that will facilitate effective teaching.
• Finally, after implementing the program, gathering feedback is essential to assess its
effectiveness and make improvements for future training.

72. 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.
A. Inform the unit manager of the incident.
B. Speak with the AP about the incident.
C. Review the chart for non-restraint alternatives for agitation.
D. Remove the restraints from the client’s wrists.
Answer: D. Remove the restraints from the client’s wrists.
Rationale:
• Patient safety first - remove it right away since there’s no order
• This is crucial for the client’s safety and well-being, as applying restraints without a
prescription can lead to physical harm and violates the client's rights. After ensuring the client
is safe, the nurse can then B. Speak with the AP about the incident to understand their
reasoning and educate them on the appropriate protocols. Following this, it would be
appropriate to A. Inform the unit manager of the incident to ensure proper oversight and
prevent recurrence. Finally, reviewing the chart for non-restraint alternatives (C) can help
identify other strategies for managing agitation in the future.
73. 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 system for tracking client information
C. A mental health specialist on the response team
D. A network for communication between staff members and families
Answer: A. A sufficient supply of personal protective equipment
Rationale:
• Page 62: Bioterrorism is the dissemination of harmful toxins, bacteria, viruses, or pathogens
for the purpose of causing illness of death. Nurse and other health professionals must be
prepared to respond to an attack by being proficient in early detection, recognizing the
causative agent, identifying the affected community, and providing early treatment to affected
people. Need sufficient supply of personal protective equipment or else others will get
infected with either anthrax, smallpox, plague, etc.

• Participate in planning and preparation for immediate response to a bioterrorist event;
Identify potential biological agents for bioterrorism; Survey for and report bioterrorist
activity (usually to the local health department); Promptly participate in measures to contain
and control the spread of infections resulting from bioterrorist activity.
74. A parish nurse is making a referral to a community meal delivery program for a member
of the congregation. This is an example of which of the following functions of the parish
nurse?
A. Health educator
B. Liaison
C. Pastoral care provider
D. Personal health counselor
Answer: B. Liaison
Rationale:
Community ATI page 38: parish nurses promote the health and wellness of populations of
faith communities. The population often includes church members and individuals and
groups in the geographical community. They work closely with pastoral care staff,
professional health care members, and lay volunteers to provide a holistic approach to healing
(body, mind, and spirit).
Functions:
• Personal health counseling (health-risk appraisals, spiritual assessments, support for
numerous acute and chronic; actual and potential health problems)
• Liaison between faith community and local resources
• Facilitates support groups
• Spiritual support (help identify spiritual strengths for coping).
75. 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 of falls. (Select all that apply.)
A. A throw rug covering some cracked vinyl flooring in the client’s kitchen
B. Folding chairs around the kitchen table
C. A two-wheeled walker to assist the client with ambulation
D. A raised vinyl seat on the toilet in the client’s bathroom
E. A wheeled office chair at the client’s computer desk

Answer: A. A throw rug covering some cracked vinyl flooring in the client’s kitchen
B. Folding chairs around the kitchen table
E. A wheeled office chair at the client’s computer desk
Rationale:
• Leadership (7.0, new version) pg 56 and avoid using full side bed rails for client who get
out of bed or attempt to get out of bed bed without assistance.
• Provide the client with nonskid footwear
• Keep the floor free from clutter with a clear path to the bathroom (no scatter rugs, cords,
furniture).
• Ensure adequate lighting
• Keep assistive devices (glasses, walker, transfer devices) nearby after validation of safe use
by the client and family.
• Educate the client and family/caregivers on identified risks and the plan of care.
• Lock wheels on beds, wheelchairs, and carts to prevent the device from rolling during
transfers or stops.
• Use chairs or bed sensors to alert staff of independent ambulation for clients at risk of
getting up unattended.
76. A nurse suggest respite care for the partner of a client who has mild impairment. The
client’s partner asks the nurse how that would help. The nurse should explain that respite care
would do which of the following?
A. Allow her to take time off attending to her partner.
B. Send a clinician to assess the safety of leaving her partner alone.
C. Help her arrange transferring her partner to an assisted living facility.
D. Provide volunteers who will run errands for her.
Answer: A. Allow her to take time off attending to her partner.
Rationale:
• Respite care is temporary institutional care of dependent elderly, ill, or handicapped person,
providing relief or rest for their usual caregivers.
• Respite care provides temporary relief for caregivers, enabling them to rest and recharge,
which is vital for their well-being. This support can help prevent caregiver burnout and
ensure that the partner can continue to provide effective care in the long run. While other
options may be beneficial in different contexts, they do not directly address the immediate

need for a break from caregiving responsibilities. Respite care can include various services,
but the primary purpose is to give the caregiver time to themselves.
77. A case manager observes a family member of a client who has Alzheimer’s disease
throwing books on the floor and sobbing while the client is having a diagnostic test. Which of
the following actions should the case manager take first?
A. Refer the caregiver to a local support group.
B. Help the caregiver arrange for respite care.
C. Offer to have a brief talk with the caregiver.
D. Consult social services to explore counseling.
Answer: C. Offer to have a brief talk with the caregiver.
Rationale:
• Talk to them first to assess and then refer them.
• This action is essential as it provides immediate emotional support to the caregiver, who is
clearly distressed. A brief conversation can help the caregiver feel heard and may allow the
case manager to assess their needs and emotional state more effectively. Establishing rapport
and offering support can be the first step in connecting the caregiver with additional
resources, such as support groups or counseling, later on. Addressing the caregiver's
immediate emotional turmoil is a priority before exploring other options.
78. A nurse is preparing to transcribe a client’s medication prescription in the medical record.
Which of the following should the nurse recognize as containing the essential components of
a medication order?
A. Aspirin 650 mg by mouth every 4 hr
B. NPH insulin 10 units before meals and at bedtime
C. Multivitamin every morning by mouth
D. Haloperidol 1 mg by mouth
Answer: A. Aspirin 650 mg by mouth every 4 hr
Rationale:
• Meds, Dose, Route, Time, needs to be considered on medication order.
• no route
• no dose
• no time

• This option contains all essential components of a medication order: the medication name
(Aspirin), dosage (650 mg), route of administration (by mouth), and frequency (every 4
hours). These components are crucial for ensuring safe and effective medication
administration. The other options, while indicating the medication, either lack specific
frequency or dosage details necessary for proper administration. Properly formatted orders
help prevent medication errors and ensure clear communication among healthcare providers.
79. 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 licensed practical nurse? Repeat
A. An adolescent client who is newly diagnosed with diabetes and requires teaching
regarding insulin administration
B. A young adult client who is postoperative, receiving morphine via epidural, and reports
pruritus
C. A middle adult client who had a below-the-knee amputation and requires a dressing
change
D. An older adult client who has lung cancer and has periodic episodes of severe dyspnea
Answer: C. A middle adult client who had a below-the-knee amputation and requires a
dressing change
Rationale:
• Leadership 6.0 (2013 version) pg 12:
• Nurses can only delegate tasks appropriate for the skill and education level of the health
care provider who is receiving the assignment
• RNs cannot delegate the nursing process, client education, or tasks that require clinical
judgement to LPNs or AP.
This task falls within the scope of practice for a licensed practical nurse (LPN), who is
trained to perform routine dressing changes and basic wound care. The other options involve
more complex assessments and education, which are typically the responsibility of registered
nurses (RNs). For instance, teaching a client about insulin administration requires a higher
level of understanding and education, while managing a postoperative client with potential
complications or assessing severe dyspnea in an older adult client also necessitates RN-level
skills.
80. A charge nurse is receiving change-of-shift report. Which of the following situations
should the charge nurse address first?

A. The emergency department is waiting to give report on a new admission
B. A nurse on the previous shift wrote an incident report about a medication error
C. Transport assistance is unavailable to take a client to occupational therapy
D. Two staff members have called to say they will be absent
Answer: D. Two staff members have called to say they will be absent
Rationale:
• Although it is from the previous shift, still need to continue on monitoring
• This situation should be addressed first because staffing levels are crucial for ensuring
patient safety and adequate care. An unexpected absence can lead to increased workload for
remaining staff, potentially compromising patient care. While other situations, like a
medication error or waiting for a new admission, are important, resolving staffing issues
takes precedence to maintain safe nurse-to-patient ratios. Additionally, addressing staffing
concerns promptly can help prevent further complications or delays in patient care.
81. A nurse is caring for a client who has early stage Alzheimer’s disease. In which of the
following actions is the nurse acting as a client advocate?
A. Requesting a referral for the client to attend reminiscent therapy sessions
B. Reorienting the client several times throughout the day
C. Performing an updated cognitive assessment on the client
D. Providing assistance for the client when ambulating down the hall
Answer: A. Requesting a referral for the client to attend reminiscent therapy sessions
Rationale:
• Reminiscence Therapy (RT) involves the discussion of past activities, events and
experiences with another person or group of people, usually with the aid of tangible prompts
such as photographs, household and other familiar items from the past, music and archive
sound recordings
• This action demonstrates client advocacy by promoting the client's emotional and cognitive
well-being through a therapeutic approach that encourages memory and engagement with
past experiences. Advocating for appropriate interventions helps enhance the client's quality
of life and supports their individuality. While the other options are important for care, they
are more focused on immediate needs rather than actively seeking beneficial therapies that
align with the client's interests and history. This proactive approach reflects the nurse's
commitment to the client's overall health and therapeutic needs.

82. 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. Return unused supplies from the bedside to the unit’s supply stock.
C. Wait to dispose of sharps containers until they are completely full.
D. Store opened bottles of normal saline in a refrigerator for up to 48 hr.
Answer: A. Use clean gloves rather than sterile gloves for colostomy care.
Rationale:
• Leadership 7.0 pg 18:
• Cost containment: strategies that promote efficient and competent client care while also
producing needed revenues for the continued productivity of the organization.
• Example: returning uncontaminated, unused equipment to the appropriate department for
credit
• This practice is appropriate as colostomy care typically does not require sterile technique,
allowing for the use of clean gloves instead. This approach helps reduce costs by minimizing
the use of more expensive sterile supplies while still maintaining effective infection control.
Other options, such as returning unused supplies to stock or waiting to dispose of sharps
containers, could compromise safety and infection control standards, making them
inappropriate for cost-containment strategies. Proper storage of opened saline also raises
concerns about sterility and safety.
83. A nurse working on a medical-surgical unit is receiving shift report regarding four clients.
Which of the following clients should the nurse see first?
A. A 50-year-old client reporting abdominal pain of 7 on a scale of 0 to 10
B. An 80-year-old client who has a urinary tract infection and a temperature of 39.2C
(100.8F)
C. A 75-year-old client who has pneumonia and has an O2 saturation of 92%
D. A 45-year-old client who has new onset of confusion 24 hr after a total hip arthroplasty.
Answer: D. A 45-year-old client who has new onset of confusion 24 hr after a total hip
arthroplasty.
Rationale:
• Leadership 7.0 page 5-6:
• ABC framework

• Circulation is necessary for oxygenated blood to reach the body’s tissue
• This client is a high priority because new confusion in a postoperative patient may indicate
serious complications such as delirium, hypoxia, or neurological issues. Prompt assessment is
crucial to identify the cause and initiate appropriate interventions. While the other clients also
require attention, the potential severity of the confusion in a relatively young patient after
surgery makes it the most urgent situation. Abdominal pain, urinary tract infection, and low
oxygen saturation are concerning but less immediate compared to the risk of significant
complications from confusion.
84. A nurse manager is reviewing the nursing code of ethics with the staff nurses. Which of
the following statements by a staff nurse indicate understanding of the teaching (Select all
that apply).
A. “The family of a newly admitted client recently treated me to lunch in the hospital
cafeteria.”
B. “I will attend continuing education classes for professional growth.”
C. “I can delegate the removal of an IV catheter to an LPN on the unit.”
D. “I administer pain medication to my clients even if they have a history of narcotic
addiction.”
E. “I have the assistive personnel double-check packed RBCs when other nurses are busy.”
Answer: B. “I will attend continuing education classes for professional growth.”
C. “I can delegate the removal of an IV catheter to an LPN on the unit.”
D. “I administer pain medication to my clients even if they have a history of narcotic
addiction.”
Rationale:
• A LPN can d/c an IV line but, not a PICC, or anything higher rated than that.
• These statements reflect a commitment to professional development, understanding of
appropriate delegation within the nursing team, and adherence to ethical principles regarding
pain management. Attending continuing education is essential for maintaining competence.
Delegating tasks appropriately aligns with the scope of practice. Administering pain
medication, regardless of a client's history, demonstrates a commitment to patient-centered
care and managing pain effectively.
85. A nurse is discussing advance directives with a client. Which of the following statements
by the client indicates an understanding of advance directives?

A. “I know I have the right to determine if I remain on a breathing machine.”
B. “I know I’ll need a lawyer to change them later, so I want to get them right.”
C. “By naming a health care proxy, I give up the right to make my own medical decisions.”
D. “I trust my doctor, so I’m going to leave it to him to do what’s best for me.”
Answer: A. “I know I have the right to determine if I remain on a breathing machine.”
Rationale:
• Leadership (7.0) page 38-39
• To communicate a client’s wishes regarding end-of-life care should the client become
unable to do so.
• This statement reflects the client's understanding that advance directives allow individuals
to express their wishes regarding medical treatment and life-sustaining measures. Advance
directives empower clients to make decisions about their care, including whether to continue
or discontinue life support.
• In contrast, statement B misrepresents the legal requirements; changes to advance directives
can often be made without a lawyer. Statement C incorrectly implies that naming a health
care proxy eliminates personal decision-making rights. Statement D indicates a lack of
understanding about the purpose of advance directives, which is to ensure that the patient's
preferences are honored, regardless of the doctor's opinion.
86. A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of
the following actions should the nurse manager take first?
A. Document a factual description of the situation
B. Remove the nurse from the unit
C. Have a blood alcohol level drawn from the nurse
D. Report the situation to the director of nursing
Answer: B. Remove the nurse from the unit
Rationale:
• It would be the first thing the nurse manager would do.
• patient’s safety first
• This step is crucial to ensure the safety of patients and staff, as the nurse's ability to provide
safe care may be compromised. Immediate removal helps prevent potential harm to clients
and allows for an investigation to be conducted in a more appropriate setting. While
documenting the situation, drawing a blood alcohol level, and reporting to the director of

nursing are important, they should occur after ensuring that the nurse is not practicing under
the influence. The priority is patient safety.
87. A nurse is assisting with the 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. Recommend that he take time to plan at the beginning of his shift
B. Advise him to complete less time-consuming tasks first
C. Ask other staff members to take over some of his tasks
D. Offer to provide care for his clients while he takes a break
Answer: A. Recommend that he take time to plan at the beginning of his shift
Rationale:
• Leadership (7.0) pg 10:
• Orientation helps newly licensed nurses translate the knowledge, skills, and attitudes
learned in nursing school into practice.
• Time Management; ATI Practice B
88. 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 medicalsurgical unit? Repeat
A. A client who gave birth to her first child and required instruction on breastfeeding
techniques
B. A client who is 2 days post-operative following a caesarean birth and is having difficulty
ambulating
C. A client who is post term and is receiving oxytocin for labor induction
D. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion
Answer: B. A client who is 2 days post-operative following a caesarean birth and is having
difficulty ambulating
Rationale:
• A medical surgical nurse can help this patient. The other choices require a nurse who knows
a great deal of OB to help these patients.
89. A home health nurse is assessing the home environment of a client who is on continuous
oxygen therapy. Which of the following findings requires the nurse to intervene?

A. The windows of the client’s room are open.
B. The client is covered with a woollen blanket.
C. The oxygen machine has grounded plug.
D. The family keeps a spare oxygen tank in the room.
Answer: B. The client is covered with a woollen blanket.
Rationale:
Wool can generate static electricity, which poses a fire risk in an environment where oxygen
is present. This is critical because oxygen can enhance combustion. While the other findings
might not be ideal (e.g., spare oxygen tanks should be stored properly), they do not pose the
same immediate risk as the use of a woollen blanket. Ensuring the client’s safety in a home
oxygen therapy setting is paramount, making it essential to address any potential sources of
ignition or static electricity.
90. A nurse is caring for a client who has a pressure ulcer on the coccyx. Which of the
following findings indicated the need for referral to a wound care specialist?
A. Minimal signs of induration at the wound edges
B. Presence of granulated tissue over the wound
C. Presence of slough in the wound bed
D. Epithelialization noted in areas of tissue loss
Answer: C. Presence of slough in the wound bed
Rationale:
Tissue types – Assess characteristics, amount (document in percentage) &location Necrotic
Tissue – dead; non-viable
• Slough – yellow, green, grey, nonviable (necrotic) tissue, usually lighter in color, thin, wet
stringy. Can be mistaken for a tendon because of the yellowish color. Debridement is
necessary to stage the wound.
• Eschar – black, brown, dry, nonviable (necrotic) tissue, usually darker in color, thicker, hard
• Epithelial tissue – deep pink to pearly pink, light purple from edges in full thickness wounds
or may form islands in superficial wounds
• Granulation tissue – beefy red, puffy or mounded bubbly appearance
• Hyper granulation tissue – granulation tissue forms above the surface of the surrounding
epithelium. Delays epithelialization.

91. A nurse on a medical-surgical unit delegating client care. Which of the following tasks
should the nurse delegate to an assistive personnel?
A. Instructing a client on self-administration of a tap water enema
B. Using a pain rating scale to monitor a client’s pain level - assessment - RN role
C. Suctioning a client’s long-term tracheostomy
D. Performing a dressing change on a client’s peripherally inserted central catheter
Answer: C. Suctioning a client’s long-term tracheostomy
Rationale:
• On practice tests; says AP can suction. I think key word here is long-term - patient had it for
a long time so AP can suction since it’s a norm...i’m talking too much, ok i shut up now LOL.
• This task can be delegated to assistive personnel (AP) who have been trained in the
procedure and understand infection control measures. The other options involve more
complex assessments or teaching that require the clinical judgment and expertise of a
registered nurse. Instructing clients on self-administration of an enema and performing a
dressing change on a central catheter require RN oversight to ensure safety and proper
technique. Therefore, suctioning is the most appropriate task for delegation in this scenario.
92. A nurse is providing teaching about infection control measures to a client who has an
indwelling urinary catheter. Which of the following instructions should the nurse include in
the teaching?
A. Clean the end of the tubing with soap and water before reconnecting it.
B. Allow urine to pool in the tubing at night
C. Use sterile technique to collect specimens from the drainage system.
D. Empty the drainage bag every 12 hr. (6 hours)
Answer: C. Use sterile technique to collect specimens from the drainage system.
Rationale:
• Fundamentals 7.0: pg 245
• Specimen collection: sterile for specimens from a catheter. Obtain a sterile specimen from a
straight or indwelling catheter using surgical asepsis (sterile technique)
• This is essential to prevent contamination and reduce the risk of infection when obtaining
urine specimens. The other options are incorrect: cleaning the tubing with soap and water is
not recommended as it can introduce bacteria; allowing urine to pool in the tubing can lead to
backflow and increase infection risk; and the drainage bag should be emptied at least every 6

hours to prevent overflow and maintain catheter function. Thus, emphasizing sterile
technique is critical in infection control for clients with indwelling catheters.
93. 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 appropriate action by the nurse?
A. Obtain a provider’s prescription for a blood alcohol level.
B. Tell the client that a catheter will be inserted
C. Assess the client for urinary retention
D. Document the client’s refusal in the chart
Answer: D. Document the client’s refusal in the chart
Rationale:
• Leadership 7.0 page 35
• Refusal of treatment
• All clients must be informed of their right to accept or refuse care.
• Competent adults have the right to refuse treatment. The client is asked to sign a document
indicating that he understands the risk involved with refusing the procedure or treatment, and
that he has chose to refuse it.
• Nurse carefully documents the information that was provided to the client and that
notification of the provider occurred.
94. A nurse manager is preparing an in service for a group of staff nurses about organ
donation. Which of the following information should the manager include?
A. Organ donation alters the appearance of the body for funeral-related viewing
B. Nurses caring for clients at the time of death may request organ donation
C. The donor’s family will incur costs related to harvesting the anatomical gift
D. Nurses may witness the signing of organ donation consents.
Answer: D. Nurses may witness the signing of organ donation consents.
Rationale:
• The nurse’s job is to reinforce explanations throughout the organ retrieval process. The
family must know who legally can give final consent, what options there are for organ or
tissue donation, and how donation will affect burial or cremation. Any nurse who could be
working in this capacity should review their state’s organ retrieval laws and institutional
policies and procedures regarding the final consent process.

• Leadership 7.0: pg 46: Nurse are responsible for answering questions regarding the
donation process and for providing emotional support to family members.
95. 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. “This won’t take long and it will be over before you know it.”
B. “It’s not too late to cancel the surgery if you want to.”
C. “Why did you make the decision to have this procedure?”
D. “You shouldn’t be worried because the procedure is very safe.”
Answer: B. “It’s not too late to cancel the surgery if you want to.”
Rationale:
• Don’t ask why! & rape is def out of the question!
• This response acknowledges the client’s emotional state and empowers her by providing the
option to reconsider the procedure. It is essential for the nurse to validate the client's feelings
and encourage open communication about her concerns. The other options either minimize
her feelings, shift focus away from her distress, or imply that her feelings are unwarranted,
which may not address her emotional needs effectively. This approach fosters a supportive
environment where the client feels heard and respected.
96. A charge nurse is observing a newly licensed nurse insert an NG tube and connect it to a
suction source. Which of the following actions by the newly licensed nurse demonstrates an
understanding of the process?
A. Inserts an 8-French NG tube
B. Dons sterile gloves for the insertion procedure - no; clean gloves
C. Clamps the air vent tubing
D. Sets the suction to 90 mmHg- 120mmHg intermittent
Answer: C. Clamps the air vent tubing
Rationale:
• Fundamentals 7.0 pg 322: Clamp the NG tube, or connect it to the suction device.
• This action demonstrates understanding of the proper suction settings for an NG tube, which
should be set to a safe and effective range to avoid damaging the mucosa. The other options
are incorrect: an 8-French NG tube may be too small for many clinical indications; sterile
gloves are not necessary for NG tube insertion, as clean gloves are sufficient; and the air vent
tubing should never be clamped, as it can lead to a risk of aspiration or damage to the gastric

mucosa. Proper understanding and adherence to these principles ensure safe and effective
patient care.
97. A nurse administrator is using benchmarking as a control criteria while reviewing current
policies and procedures. Which of the following actions should the nurse take?
A. Compare practices within the facility against other high-performing facilities
B. Use root cause analysis to identify gaps in meeting standards.
C. Determine how current practice will affect future performance within the facility
D. Establish work initiatives to promote a positive environment
Answer: A. Compare practices within the facility against other high-performing facilities
Rationale:
• A root cause analysis can be done to critically assess all factors that influence the issues. It
focuses on variable that surround the consequence of an action or occurrence.
• Benchmarking involves assessing processes, outcomes, and best practices against those of
leading organizations to identify areas for improvement. This approach helps the facility
understand its performance relative to others and identify effective strategies to enhance
quality and efficiency. Options B, C, and D are important for quality improvement but do not
specifically align with the benchmarking process, which focuses on external comparisons.
98. A nurse working in an emergency department is performing triage. To which of the
following clients should the nurse assign priority?
A. A client who has compound fractures of the tibia and humerus
B. A client who reports severe vomiting and diarrhoea
C. A client who has soot markings around each naris following a house fire - compromise
breathing
D. A client who reports night sweats and fever for the last week
Answer: C. A client who has soot markings around each naris following a house fire compromise breathing
Rationale:
• Grey’s Anatomy!
• This client is at immediate risk for respiratory compromise due to potential inhalation
injury, which can lead to airway obstruction and respiratory distress. In emergency triage, the
priority is to address life-threatening conditions first. While the other clients have significant
issues, the potential for airway compromise makes the client with soot markings the highest

priority. The nurse must assess and intervene quickly to ensure adequate oxygenation and
ventilation.
99. A nurse is providing discharge teaching to a client following a total knee arthroplasty.
Which of the following information should the nurse include? (Select all that apply.)
A. Contact information for the physical therapist
B. Insurance information
C. Medication guideline information
D. Advance directives information
E. Information about follow-up care
Answer: A. Contact information for the physical therapist
C. Medication guideline information
E. Information about follow-up care
Rationale:
• Essential for ongoing rehabilitation and recovery after surgery.
• Important for managing pain and preventing complications; clients need to know how and
when to take their medications.
• Critical for monitoring recovery and addressing any concerns post-discharge.
100. A nurse manager overhears a provider and a staff talking about a client’s diagnosis in the
cafeteria. Which of the following actions should the nurse take first?
A. Fill out an incident report regarding the situation
B. Provide a staff in service about client confidentiality
C. Report the incident to the nursing supervisor
D. Remind them that client information is confidential
Answer: D. Remind them that client information is confidential
Rationale:
• Key word is what should the nurse manager do first
• This action addresses the issue immediately and reinforces the importance of confidentiality
in a straightforward manner.
• It provides an opportunity for the provider and staff to correct their behavior in real-time.
• This approach promotes a culture of awareness regarding patient privacy without escalating
the situation prematurely.

• It can serve as a teaching moment for the involved parties about appropriate settings for
discussing sensitive information.
• Taking immediate corrective action supports adherence to HIPAA regulations and protects
patient rights.
101. A nurse receives change-of-shift report for the following four clients. Which of the
following clients should the nurse assess first?
A. An older adult client who has bacterial pneumonia and a new onset of restlessness
B. A middle adult client who has diabetes mellitus and a morning blood glucose of 172
mg/dL
C. A client who has myasthenia gravis with ptosis and has developed urinary incontinence
D. A client who is 1 day postoperative following hip fracture repair and reports a pain level of
6 on a scale from 0 to 10
Answer: A. An older adult client who has bacterial pneumonia and a new onset of
restlessness
Rationale:
• ABCs; key word is new onset
• New onset of restlessness in an older adult with bacterial pneumonia may indicate hypoxia,
infection progression, or confusion, all of which require immediate assessment.
• This client's respiratory status is critical; changes can quickly lead to deterioration.
• Assessing for signs of hypoxia or changes in mental status can help identify urgent
interventions needed.
• The other clients, while requiring attention, do not present as immediate threats to life or
health compared to the potential complications faced by the pneumonia patient.
• Prioritizing clients based on acuity is essential in ensuring safety and effective care delivery
in a nursing setting.
102. A nurse enters a client’s room and observes a fire in the trash can. Identify the sequence
of actions the nurse should take. (Move all the actions into the box on the right, placing them
in selected order of performance.)
A. Remove the client from the area.
B. Activate the fire alarm system.
C. Confine the fire by closing doors and windows.
D. Extinguish the fire if possible.

Answer: A. Remove the client from the area.
B. Activate the fire alarm system.
C. Confine the fire by closing doors and windows.
D. Extinguish the fire if possible.
Rationale:
• Remove the client first to ensure their safety from immediate danger.
• Activate the fire alarm to alert others and initiate emergency protocols.
• Confine the fire by closing doors and windows to prevent its spread.
• Finally, extinguish the fire if safe to do so, as this can help control the situation quickly.
• Following the RACE (Rescue, Alarm, Contain, Extinguish) protocol ensures a systematic
and effective response to fire emergencies.
103. A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
A. Reviewing dietary instructions for a client who has kidney stones
B. Monitoring a client who has a fluid restriction
C. Obtaining a stool sample from a client who has renal failure
D. Assessing a client who just returned from haemodialysis
Answer: C. Obtaining a stool sample from a client who has renal failure
Rationale:
This task is within the scope of practice for assistive personnel, as it does not require
assessment or critical thinking. The other options involve monitoring, assessing, or providing
education, which should be performed by a licensed nurse.
104. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a
sterile procedure. Which of the following actions indicated the nurse is maintaining sterile
techniques (Select all that apply.)
A. Removes the outside packaging of a sterile instrument before dropping it onto the sterile
field
B. Rests the cap of a solution container upside down on the sterile field
C. Assessing a client who just returned from haemodialysis
D. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field. 1 inch border not sterile

Answer: A. Removes the outside packaging of a sterile instrument before dropping it onto
the sterile field
Rationale:
• Fundamentals 7.0 page 46-4
• Removing the outside packaging of a sterile instrument before placing it on the sterile field
ensures that any non-sterile surfaces do not contaminate the sterile area.
105. A nurse is preparing a client for a 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?
A. Convey the client’s request to the nurse who witnessed the consent.
B. Explain the risks of the procedure to the client.
C. Check to see if the medical record indicated the provider explained the procedure to the
client.
D. Notify the provider about the client’s concerns.
Answer: D. Notify the provider about the client’s concerns.
Rationale:
• The nurse is not responsible for explaining the risks and benefits of the procedure; this is the
provider’s role.
• Notifying the provider ensures that the client receives accurate information directly from the
qualified professional who can address their concerns thoroughly.
• It also maintains the integrity of the informed consent process, ensuring the client is fully
informed before proceeding.
• The nurse should facilitate communication between the client and provider, reinforcing the
importance of understanding the procedure.
• Addressing client concerns is essential for promoting trust and satisfaction with their care.
106. 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. Please ask your relative about this, because I cannot share information about her.
B. I will have your relatives nurse come and talk with you about her care.
C. I’m not taking care of your relative today, so I don’t have the latest information
D. Let me check your relatives medical record to see how she’s doing
Answer: A. Please ask your relative about this, because I cannot share information about her.

Rationale:
• This response maintains patient confidentiality as mandated by HIPAA (Health Insurance
Portability and Accountability Act).
• It reinforces the principle that only the patient or their designated representatives can
receive medical information.
• The nurse's priority is to protect the client's privacy and adhere to ethical standards in
healthcare.
• Encouraging the visitor to ask the relative directly empowers the patient and respects their
autonomy.
• This approach also avoids any potential breaches of confidentiality that could occur by
sharing information with unauthorized individuals.
107. A charge nurse observes a client fall during ambulation and notes that his gait belt was
not place. In reviewing the incident report, the nurse finds no mention of gait belt. Which of
the following ethical principles should guide the nurses subsequent actions?
A. Fidelity
B. Beneficence
C. Nonmaleficence
D. Veracity
Answer: D. Veracity
Rationale:
• State the truth of the gait belt in the incident report.
• Veracity refers to the obligation of healthcare providers to tell the truth and provide accurate
information.
• In this situation, the nurse must report the facts surrounding the incident honestly, including
the absence of the gait belt, to ensure accountability and transparency.
• Upholding veracity helps to maintain trust between the healthcare team and the clients, as
well as among team members.
• Accurately documenting the incident is essential for investigating the cause of the fall and
preventing future occurrences.
• This principle supports ethical practices in nursing by fostering an environment of honesty
and integrity in patient care.

108. A charge nurse is making assignments for a med surg unit. Which of the following
clients is appropriate to assign to a licensed practical nurse?
A. A client who is scheduled to start oral nutrition 2 days after cerebrovascular accident
B. A client who has dehydration and is being admitted from the ER
C. A client who as emphysema and has oxygen saturation level of 92%
D. A client who is scheduled to receive 2 units of RBCs following hip replacement
Answer: C. A client who as emphysema and has oxygen saturation level of 92%
Rationale:
• Leadership 6.0 (2013 version) pg 12:
• Nurses can only delegate tasks appropriate for the skill and education level of the health
care provider who is receiving the assignment
• RNs cannot delegate the nursing process, client education, or tasks that require clinical
judgement to LPNs or AP.
• Licensed Practical Nurses (LPNs) are equipped to care for stable patients with chronic
conditions, such as emphysema, as long as there are no immediate complications.
• The client with an oxygen saturation level of 92% may need monitoring, but this can
typically be managed by an LPN under the supervision of an RN.
• The other options involve more complex care or require nursing assessments that are
typically performed by RNs, such as evaluating post-stroke nutritional needs (A), managing a
client being admitted for dehydration (B), and overseeing blood transfusions (D), which
involve critical decision-making and monitoring for potential complications.
109. A charge nurse in the ER is supervising a nurse who is floating from the medicalsurgical unit. Which of the following assignments is appropriate for the float nurse?
A. Complete a Sad Persons assessment scale for the client who has attempted suicide-why
not this one?
B. Perform a urinary catheterization for a client who has experienced a cerebrovascular
accident
C. Administer IV nitro-glycerine to a client who is experiencing chest pain
D. Set up a trauma room for an incoming client who was in a motor vehicle crash.
Answer: B. Perform a urinary catheterization for a client who has experienced a
cerebrovascular accident
Rationale:

It is part of their scope practice for a medical surgical nurse to insert a urinary catheterization
for patient who has CVA. this is the most stable patient a floated nurse could have.
• Performing urinary catheterization is a skill typically within the scope of practice for nurses
on a medical-surgical unit, and a float nurse should be familiar with this procedure.
• Option A (completing a Sad Persons assessment scale for a client who has attempted
suicide) may require specific training or experience in mental health assessments, which the
float nurse may not have.
• Option C (administering IV nitro-glycerine) is more critical and requires monitoring and
expertise in managing cardiac patients, which might not be within the float nurse's
competency.
• Option D (setting up a trauma room) involves high-pressure decision-making and
familiarity with ER protocols, which the float nurse may not have.
110. 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?
A. Access a language line to interpret what is being said
B. Ask the client’s daughter to interpret the conversation
C. Talk loudly while facing the client
D. Request the assistance of an assistive personnel who speaks the client’s language
Answer: A. Access a language line to interpret what is being said
Rationale:
• Using a professional interpreter ensures accurate communication and helps maintain
confidentiality and professionalism during the admission process.
• Option B (asking the daughter to interpret) may lead to misunderstandings and could
compromise the patient's privacy and comfort.
• Option C (talking loudly while facing the client) is ineffective and disrespectful; it does not
facilitate proper communication.
• Option D (requesting an assistive personnel who speaks the client’s language) is not ideal
unless that personnel is a trained interpreter, as it may not ensure the same level of accuracy
and confidentiality as a professional language service.
111. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is
appropriate to delegate to a LPN?

A. Instructing a client who is obese about a low-fat diet
B. Providing the first oral feeding to a client following a stroke
C. Changing the dressing on a postoperative wound
D. Referring a client to social services for assistance with transportation.
Answer: C. Changing the dressing on a postoperative wound
Rationale:
• ATI 2016 pg.
• LPNs are trained and permitted to perform wound care, including changing dressings for
postoperative patients, as this falls within their scope of practice.
• Option A (instructing a client about a low-fat diet) typically requires a registered nurse (RN)
or dietitian, as it involves comprehensive patient education and assessment.
• Option B (providing the first oral feeding to a client following a stroke) should be done by
an RN, as it requires evaluation of the client’s swallowing abilities and risk of aspiration.
• Option D (referring a client to social services) usually falls under the responsibilities of an
RN, who can assess the client's overall needs and coordinate care effectively.
112. A nurse is caring for a client who has an MI. The client’s daughter ask the nurse to
review her father’s medical with her. Which of the following responses should the nurse
make?
A. “I can tell you what the provider has written in the progress notes.”
B. “We’ll ask your father’s provider to show you the laboratory results.”
C. “You’ll have to make that request in writing in the medical records department.”
D. “Your father will have to give permission for you to review the record.”
Answer: D. “Your father will have to give permission for you to review the record.”
Rationale:
• Patient confidentiality is a key principle in healthcare, and medical records are protected
under laws such as HIPAA (Health Insurance Portability and Accountability Act). The client
must provide consent for family members to access their medical information.
• Option A is inappropriate as it implies the nurse can disclose detailed information that may
not be permissible.
• Option B misrepresents the provider's role; they typically won't show lab results directly to
family members without consent.
• Option C may be true in some contexts, but it does not address the immediate need for
consent from the patient, making it less relevant in this situation.

113. A nurse in a clinic is reviewing lab reports for a group of clients. Which of the following
diseases should the nurse report to the state health departments?
A. Rotavirus
B. Group B streptococcal disease
C. Respiratory syncytial virus
D. Pertussis
Answer: D. Pertussis
Rationale:
• Pertussis, or whooping cough, is a highly contagious bacterial disease that is required to be
reported to state health departments due to its potential for outbreaks and serious
complications, especially in infants and vulnerable populations.
• Option A (Rotavirus) is common but not typically mandated for reporting in all states.
• Option B (Group B streptococcal disease) is significant but reporting requirements can vary
by state and situation.
• Option C (Respiratory syncytial virus) (RSV) is also common and often does not require
reporting unless there are unusual outbreaks or severe cases.
114. A nurse is the ER is caring for a 16 year old client who reports abdominal pain and is
accompanied by an adult neighbour. The provider diagnoses a ruptured appendix and states
that the client requires an emergency appendectomy. Which of the following actions should
the nurse take?
A. Ask the adult neighbour to sign the consent form.
B. Attempt to notify the client’s guardian to obtain consent.
C. Witness the client signing the consent form.
D. Obtain consent from the hospital administrator.
Answer: B. Attempt to notify the client’s guardian to obtain consent.
Rationale:
• For a minor (under 18 years old), informed consent for medical procedures generally must
be obtained from a parent or legal guardian unless specific exceptions apply (such as
emergencies).
• In this case, the client requires an emergency appendectomy, so the nurse should promptly
attempt to contact the guardian for consent, given that the situation is urgent and the client
cannot provide consent themselves.

• Option A (asking the adult neighbour to sign) is inappropriate unless the neighbour has legal
guardianship or consent authority.
• Option C (witnessing the client signing) is not valid, as minors typically cannot legally
consent to their own medical treatment.
• Option D (obtaining consent from the hospital administrator) is unnecessary and not
standard practice in this situation.
115. A nurse is teaching a client who requires protective isolation due to immune system
compromise. Which of the following instructions should the nurse include to protect the
client?
A. “Make sure your visitors wear a gown when they are in your room.”
B. “Remember to tell your family and friends not to bring you flowers.”
C. “Wear gloves and a gown whenever you need to leave your room.”
D. “Be sure to eat plenty of fresh fruit and vegetables.”
Answer: B. “Remember to tell your family and friends not to bring you flowers.”
Rationale:
• No live plants or flowers are allowed in the patient's room. Fruit and vegetables should be
packaged or peeled and dairy products should be individually packaged and pasteurised.
• Clients in protective isolation have compromised immune systems and are at a higher risk
of infection. Fresh flowers can harbour bacteria and fungi, which can be harmful to these
clients.
• Option A is incorrect because while visitors may need to wear gowns, masks, or gloves
depending on the facility's policy, it is not the primary focus for protecting the client from
environmental risks.
• Option C is also incorrect; clients typically do not need to wear gloves and gowns when
leaving their room, as this could limit mobility and quality of life.
• Option D is inappropriate as well; clients with compromised immune systems should avoid
raw fruits and vegetables due to the risk of foodborne illness. They should consume wellcooked foods instead.
116. A nurse in the emergency department is preparing a married 17-year-old client for an
appendectomy. The client’s parents are en route to the facility but have not spoken with the
surgeon. Which of the following actions should the nurse take?
A. Have the client sign the consent form after the surgeon explains the procedure.

B. Proceed with the preparation because the client signed a general consent form.
C. Obtain consent from the client’s parents by telephone with another nurse listening as a
witness.
D. Delay the surgery until the parents arrive to sign the consent form.
Answer: A. Have the client sign the consent form after the surgeon explains the procedure.
Rationale:
• ATI 16 pg. 36 Emancipated minors (minors who are independent from their parents, such as
a married minor) can provide informed consent for themselves.
• In many jurisdictions, a married minor is considered an emancipated individual, which
means they can make medical decisions for themselves without needing parental consent.
This legal status typically allows them to sign consent forms for procedures.
117. 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?
A. “I understand, and it’s not too late to change your mind.”
B. “You’ll be fine. You’ll receive a prescription for pain medication.”
C. “Why didn’t you discuss your concerns with your provider.”
D. “If you have the procedure now, you won’t have to deal with pain and disability later.”
Answer: A. “I understand, and it’s not too late to change your mind.”
Rationale:
• Patient advocate. And respecting autonomy. The rest are non therapeutic response.
• This response acknowledges the client’s feelings and fears about pain, which is important
for building trust and rapport.
• It reinforces the client’s right to reconsider their decision about the surgery, emphasizing
that consent can be withdrawn at any time.
118. 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
Rationale:
• ATI 16 pg. 42 Intentional Torts: Battery: Intentional and wrongful physical contact with a
person that involves an injury or offensive contact (restraining a client and administering an
injection against his wishes).
• Battery involves the intentional and unauthorized physical contact with another person,
which can include administering a medication without the individual's consent.
• The client specifically refused the intramuscular (IM) medication, and administering it
against their will constitutes battery.
119. A nurse is completing discharge teaching with a client who is being treated with
tuberculosis (TB). Which of the following statements by the client indicates an understanding
of the teaching?
A. “I need to take my prescribed medication for 3 months.” 6-12 months
B. “I need to have a TB skin test done once per year.”
C. “I should wear a mask while around my family.”
D. “I should have a sputum culture done every 2 to 4 weeks.”
Answer: D. “I should have a sputum culture done every 2 to 4 weeks.”
Rationale:
• Examination of the sputum of patients with pulmonary tuberculosis at 2- to 4-week intervals
until conversion occurs is important for several reasons.
• Sputum cultures are essential for monitoring the effectiveness of TB treatment and ensuring
the client is no longer contagious.
120. 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. Transport the client to the operating room without verifying informed consent.
D. Ask the anaesthesiologist to sign the consent.
Answer: C. Transport the client to the operating room without verifying informed consent.
Rationale:

• Research. The health care providers may rely upon implied consent only in the absence of
consent. It may not be necessary to obtain consent if a person requires emergency treatment
to save their life (unconscious) -reasons why treatment was necessary should be fully
explained once they've recovered. Or an immediate requires of an additional emergency
procedure.
121. 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 to
manage the tracheostomy at home? (Select all that apply.)
A. Petroleum jelly
B. Betadine solution
C. Obturator
D. Oxygen tank
E. Suction machine
Answer: C. Obturator
D. Oxygen tank
E. Suction machine
Rationale:
• Research: Home Tracheostomy Care→ REVIEW petroleum jelly around the stoma;
Obturator when replacing the current one in your neck when cleaning; 02 patient might be
sob; suction machine for excessive mucus and maintain a patent airway while doing
tracheostomy cleaning
• ATI Practice Leadership 2016 B: The client should avoid the use of petroleum jelly b/c oils
and greases are flammable and can ignite, causing serious injury to the client. The nurse
should instruct the client to use a water-based lubricant when using oxygen.
122. A nurse is completing discharge teaching about dietary supplements for nitrogen loss
with a client who has cancer. Which of the following nutrients should the nurse recommend
the client increase?
A. Fiber
B. Fatty acids
C. Protein
D. Carbohydrates
Answer: C. Protein

Rationale:
• Research: An evaluation of protein quality must therefore take into account the different
processes involved in amino acid and nitrogen homeostasis.
• Protein is essential for maintaining nitrogen balance in the body. Increased protein intake is
crucial for clients with cancer to support tissue repair and muscle maintenance.
123. A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
A. Administer a nasogastric tube feeding
B. Pick up the meal trays after lunch
C. Determine adequacy of ventilator settings
D. Plan break times for assistive personnel
Answer: A. Administer a nasogastric tube feeding
Rationale:
• ATI 16 Pg. 9 Table 1.4 Administering enteral feedings.
• Licensed practical nurses (LPNs) are trained to administer medications and feedings,
including nasogastric tube feedings, under the supervision of registered nurses (RNs).
124. A case manager is preparing a client who has a spinal cord injury for discharge from the
rehabilitation setting to home. Which of the following actions is the case manager’s priority
when creating the discharge plan?
A. Identify desired outcomes for the client’s home care
B. Facilitate client referrals for community resources
C. Advocate strategies for cost-effective home care
D. Arrange for a home environment assessment
Answer: B. Facilitate client referrals for community resources
Rationale:
• ATI 16 Pg. 25 Facilitating referrals and the use of community resources.
• Clients with spinal cord injuries often require various community resources for ongoing
care, rehabilitation, and support. Ensuring access to these resources is crucial for their
successful transition home.

125. 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?
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.
Rationale:
The Patient Self-Determination Act (PSDA) stipulates that on admission to a health care
facility, all clients must be informed of their right to accept or refuse care. Competent adults
have the right to refuse treatment. If the client refuses a treatment or procedure, the client is
asked to sign a document indication that he understands the risk involved with refusing the
Treatment or procedure, and that he has chosen to refuse it.
126. A nurse I making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
A. Pick up the meal trays after lunch.- CNA
B. Administer a nasogastric tube feeding.
C. Plan break times for assistive personnel.
D. Determine adequacy of ventilator settings.
Answer: B. Administer a nasogastric tube feeding.
Rationale:
• LVN can do basic nursing skills
• Administering a nasogastric tube feeding is within the scope of practice for licensed
practical nurses (LPNs). They are trained to perform this task safely and effectively.
127. 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)
A. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field - 1
in.
B. Opens the sterile pack by first unfolding the top flap away from her body

C. Prepares a container of sterile solution on the field after putting on sterile gloves - before
D. Removes the outside packaging of a sterile instrument before dropping it onto the sterile
field
E. Holds the sterile solution bottle with the label facing up
Answer: B. Opens the sterile pack by first unfolding the top flap away from her body
D. Removes the outside packaging of a sterile instrument before dropping it onto the sterile
field
E. Holds the sterile solution bottle with the label facing up
Rationale:
• Hold with the label in the palm of the hand so that the solution does not run down the
label..i’m trying to visualize this, so isn’t this right because if you’re pouring, the label would
be facing up, on your palm?
• Sterile items should be placed within a 2.5 cm (1 in) border around the edges of the sterile
field to maintain sterility.
128. 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. Auscultate the client’s lungs.
B. Notify the provider.
C. Place a faulty equipment tag on the pump.
D. Complete an incident report.
Answer: A. Auscultate the client’s lungs.
Rationale:
The first priority in this situation is to assess the client for potential complications of
receiving too much IV fluid, such as fluid overload. Auscultating the lungs can help identify
signs of pulmonary edema or other fluid-related issues.
129. 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 - AP

C. Administering morphine IV bolus to a client who is hr postoperative - RN
D. Admitting a new client who has chronic back pain to the unit – RN
Answer: A. Reinforcing teaching with a client who is learning to self-administer insulin
Rationale:
Licensed practical nurses (LPNs) are trained to reinforce patient education and can help
clients understand medication administration, including insulin self-administration.
130. 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 demonstrates correct aseptic technique?
A. The nurse applies goggles.
B. The nurse turns her back to the sterile field.
C. The nurse holds her hands above her waist.
D. The nurse puts on a face mask.
Answer: C. The nurse holds her hands above her waist.
Rationale:
Holding the hands above the waist helps to maintain the sterility of the gloves and prevents
contamination. Items below the waist are considered non-sterile.
131. 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?
A. Review vital sign trends at the end of the shift.
B. Recheck vital signs that are outside the expected reference range.
C. Ask the AP to write a summary of the delegated tasks during the shift.
D. Compare the vital signs the AP obtained with those taken by another AP on a previous
shift.
Answer: A. Review vital sign trends at the end of the shift.
Rationale:
It is essential for the nurse to verify any vital signs that are abnormal to ensure the client's
safety and to determine if further intervention is needed.
132. A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?

A. Obtaining a stool sample from a client who has renal failure
B. Monitoring a client who has a fluid restriction
C. Assessing a client who just returned from haemodialysis - RN (assessment)
D. Reviewing dietary instructions for a client who has kidney stones - RN (teaching)
Answer: A. Obtaining a stool sample from a client who has renal failure
Rationale:
Assisting personnel (AP) can perform tasks that do not require clinical judgment or
assessment skills. Obtaining a stool sample is a straightforward task that does not require
nursing knowledge or assessment.
133. A nurse is triaging a group of clients following a disaster. Which of the following clients
should the nurse recommend for treatment first?
A. A client who has a neck injury and is unable to breathe spontaneously
B. A client who has two open chest wounds with a left tracheal deviation
C. A client who has major burns over 75% of her body surface area
D. A client who has bipolar disorder and is exhibiting signs of hallucination
Answer: A. A client who has a neck injury and is unable to breathe spontaneously
Rationale:
• Airway
• In triage, the primary concern is to ensure airway patency and adequate breathing. A client
who cannot breathe spontaneously requires immediate intervention to secure the airway.
134. 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?
A. “A family member can interpret to obtain informed consent from a client who is deaf.”
B. “Consent can be given by a durable power of attorney.”
C. “Guardian consent is required for an emancipated minor.”
D. “The nurse can answer any questions the client has about the procedure.”
Answer: B. “Consent can be given by a durable power of attorney.”
Rationale:
• Emancipated minors can give their own consent
• Provider is responsible for this

• A durable power of attorney for healthcare can make medical decisions on behalf of a client
who is unable to provide informed consent themselves. This is a key aspect of informed
consent guidelines.
135. A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
A. A middle adult client who leaves the facility against medical advice - right to refuse
treatment
B. An older adult client who has advanced directives on file - has advance directives
C. A young adult client who is participating in a medical research study - of age
D. An adolescent client whose parents refuse a blood transfusion for religious reasons
Answer: D. An adolescent client whose parents refuse a blood transfusion for religious
reasons
Rationale:
This situation involves ethical dilemmas regarding parental rights, the child's best interests,
and potential conflicts between religious beliefs and medical needs.
136. 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?
A. Assessing client needs
B. Developing client treatment protocols
C. Providing medication reconciliation
D. Establishing communication between providers
Answer: A. Assessing client needs
Rationale:
Telehealth aims to assess client needs remotely, allowing healthcare providers to gather
information about the client's condition and needs without requiring an in-person visit.
137. 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?
A. Refer the client to the social services department.

B. Provide the client with a week’s worth of supplies from the hospital - (still needs help
paying after)
C. Ask the provider about the possibility of less frequent monitoring - (pt needs to monitor
often)
D. Recommend the client reuse the testing lancets - (breaks the safety & infection protocol)
Answer: A. Refer the client to the social services department.
Rationale:
• Community ATI PDF p53: referral to social services to eliminate financial difficulties or
other sources of stress.
• The social services department can provide resources, support, and information about
financial assistance programs for medical supplies, including blood-glucose monitoring
supplies.
138. A charge nurse is receiving change-of-shift report. Which of the following situations
should the charge nurse 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: B. Two staff members have called to say they will be absent
Rationale:
• Leadership ATI PDF p5: Priority setting requires that decisions be made regarding the order
in which: 1. Clients are seen 2. Assessments are completed 3. Interventions are provided 4.
• Steps . - so I’m thinking this because they’re down on nurses in a client procedure are
completed 5. Components of client care are completed.
• The absence of two staff members directly affects the nursing staff-to-patient ratio and can
compromise patient safety and care delivery. Addressing staffing shortages is a priority to
ensure adequate coverage and safe patient care.
139. 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?
A. Complete required tasks.
B. Review the client’s new laboratory values.

C. Determine client care goals (set/ plan goals)
D. Document assessment data.
Answer: C. Determine client care goals (set/ plan goals)
Rationale:
Leadership ATI PDF p7: Time management is a cyclic process. Time initially spent
developing a plan will save time later and help to avoid management by crisis. Set goals and
plan care based on established priorities and thoughtful utilization of resources. Complete one
client care task before beginning the next, starting with the highest priority task. Reprioritize
remaining tasks based on continual reassessment of client care needs. At the end of the day,
perform a time analysis and determine if time was used wisely.
140. 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?
A. “Clients who participate in research studies forfeit their HIPAA right to privacy.”
B. “HIPAA allows facility-specific coding of client health care information to ensure
privacy.”
C. “HIPAA prohibits the uploading of photographs of client’s providers to social media sites.”
D. “HIPAA allows clients to request a review of their own medical records.”
Answer: D. “HIPAA allows clients to request a review of their own medical records.”
Rationale:
Leadership ATI PDF p40: The rights of clients to obtain a copy of their medical record and to
submit requests to amend erroneous or incomplete information. A requirement for healthcare
and insurance providers to provide written information about how medical information is
used and how it is shared with other entities (permission must be obtained before information
is shared). The rights of clients to privacy and confidentiality
141. 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 the risk of refusing the procedure
B. Whether the facility ethics committee reached a consensus on the case
C. Whether the partner is the client’s durable power of attorney for health care
D. Whether the client’s refusal is based on religious belief
Answer: A. Whether the client understands the risk of refusing the procedure

Rationale:
Leadership ATI PDF p35: If the client refuses a treatment or procedure, the client is asked to
sign a document indicating that he understands the risk involved with refusing the treatment
or procedure, and that he has chosen to refuse it.
142. 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 to a licensed practical nurse?
A. Conduct the newborn hearing screening.
B. Administer a hepatitis B vaccine.
C. Perform a New Ballard screening.
D. Obtain vital signs.
Answer: B. Administer a hepatitis B vaccine.
Rationale:
• Leadership ATI PDF p9: Administering medication (excluding IV medication in some
states)
• Licensed practical nurses (LPNs) are trained to administer vaccines, including the hepatitis
B vaccine, as part of their scope of practice. This task does not require the advanced
assessment skills of a registered nurse (RN).
143. 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?
A. Train LPNs to reinforce teaching with clients using a standardized teaching plan.
B. Determine factors that interfere with the documentation of client education.
C. Include documentation of client education as part of unit nurses’ annual performance
evaluation.
D. Offer incentives for the staff once the unit’s results are back in adherence with the
benchmark.
Answer: B. Determine factors that interfere with the documentation of client education.
Rationale:
• Leadership ATI PDF p12: Steps in quality improvement process:
• Standards are made available to employees by way of policies and procedures.
• Quality issues are identified by staff, management, or risk management department.

• An interprofessional team is developed to review the issue.
• The current state of structure and process related to the issue is analyzed.
• Data collection methods are determined
• Data is collected, analyzed, and compared with the established benchmark.
• If the benchmark is not met, possible influencing factors are determined. A root cause
analysis can be done to critically assess all factors that influence the issue.
• Potential solutions or corrective actions are analyzed and one is selected for
implementation.
• Educational or corrective action is implemented.
• The issue is reevaluated at a preestablished time to determine the efficacy of the solution or
corrective action.
144. 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?
A. Utility
B. Autonomy
C. Nonmaleficence
D. Veracity
Answer: C. Nonmaleficence
Rationale:
• Leadership ATI PDF p47: Nonmaleficence: The nurse’s obligation to avoid causing harm to
the client
• This ethical principle refers to the obligation to prevent harm to clients. In this case,
removing a fall hazard directly aligns with the goal of preventing injury, thereby upholding
the principle of nonmaleficence.
145. A nurse is caring for a group of clients. Which of the following clients should the nurse
plan to assess first?
A. A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past 24 hr
(improvement)
B. A client who has diabetes mellitus and reports paresthesias in his fingers and toes (ABC-circulation)
C. A client who has a nasogastric tube and has crackles in the lungs (ABC--airway)

D. A client who has a new diagnosis of Graves’ disease and a TSH level of 0.2 microunits/mL
Answer: C. A client who has a nasogastric tube and has crackles in the lungs (ABC--airway)
Rationale:
• Leadership ATI PDF p5: ABC--airway; Breathing is necessary for oxygenation of the blood
to occur.
• Means that tube is in the lungs and not in stomach. Compromises airway
• The presence of crackles in the lungs indicates potential fluid overload or aspiration, which
could compromise the airway and breathing. This situation requires immediate assessment to
ensure adequate oxygenation and to address any potential respiratory distress.
146. 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
A. A client who is in Buck’s traction for a left hip fracture (can’t necessarily move too much)
B. A client who is 1 day postoperative following thoracic surgery and has a chest tube
(possible physical instability)
C. A client who is confused and restrained for safety (still needs continual nursing
care/assessment)
D. A client who is receiving IV chemotherapy and is ambulatory
Answer: D. A client who is receiving IV chemotherapy and is ambulatory
Rationale:
Leadership ATI PDF p73: First, discharge or relocate ambulatory clients requiring minimal
care. Next, make arrangement for continuation of care for clients who require some
assistance, which could be provided in the home or tertiary care facility. Do not discharge or
relocate clients who are unstable or require continuing nursing care and assessment unless
they are in imminent danger.
147. 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?
A. Recommend the son meet with the provider to get information about his mother’s
condition.
B. Report the possible violation of client confidentiality to the nurse manager.
C. Complete an incident report regarding the breach of the client’s confidentiality.
D. Log out the computer so that the client’s son is unable to view his mother’s information.

Answer: D. Log out the computer so that the client’s son is unable to view his mother’s
information.
Rationale:
• Leadership ATI PDF p40 &42: Log off from the computer before leaving the workstation to
ensure that others cannot view protected health information (PHI) on the monitor Nurses who
disclose client information to an unauthorized person can be liable for invasion of privacy,
defamation, or slander. Intrusion into a client’s private affairs or a breach of confidentiality
• The priority is to protect the client's privacy and confidentiality. By logging out of the
computer, the nurse can immediately prevent further unauthorized access to sensitive
information.
148. 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?
A. Explain the risks of the procedure to the client. - HCP needs to do this
B. Convey the client’s request to the nurse who witnessed the consent.
C. Check to see if the medical record indicates the provider explained the procedure to the
client.
D. Notify the provider about the client’s concerns.
Answer: D. Notify the provider about the client’s concerns.
Rationale:
• Leadership PDF p47: Notify the provider if the client has more questions or does not
understand any of the information provided. (The provider is then responsible for giving
clarification.)
• The healthcare provider (HCP) is responsible for explaining the risks and benefits of the
procedure to the client. The nurse should facilitate this by notifying the provider about the
client's request for more information.
149. A nurse is prioritizing care after 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 an urge to void but has not urinated during the prior shift
C. A client who reports indigestion and pain in her jaw
D. A client who reports feeling lightheaded when he stands up from a lying position

Answer: C. A client who reports indigestion and pain in her jaw
Rationale:
• Medical surgical page 184. Subjective Data: Chest pain might occur with or without
exertion. Pain might radiate to jaw, left arm, through the back, or to the shoulder. Effects
might increase in cold weather or with exercise. Other findings can include dyspnea, nausea,
fatigue, and diaphoresis.
• Indigestion and jaw pain can be symptoms of a myocardial infarction (heart attack),
especially in women. This combination of symptoms should be taken seriously and warrants
immediate assessment.
150. 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 time management strategies with the nurses.
B. Determine the reasons the nurses are not taking scheduled breaks.
C. Provide coverage for the nurses’ breaks.
D. Review facility policies for taking scheduled breaks.
Answer: B. Determine the reasons the nurses are not taking scheduled breaks.
Rationale:
Before taking any action, it’s important to understand why the nurses are not taking their
breaks. This could be due to workload, staffing issues, or personal preferences, and
understanding the underlying reasons will help in addressing the situation effectively.
151. A nurse is preparing to delegate bathing and turning of a newly admitted client who has
end-stage bone cancer to an experienced assistive personnel (AP). Which of the following
assessments should the nurse make before delegating care?
A. Has the AP checked the client’s pain level prior to turning her?
B. Is the client’s family present so the AP can show them how to turn the client?
C. Has data been collected about specific client needs related to turning?
D. Does the AP have the time to change the client’s central IV line dressing after turning her?
Answer: C. Has data been collected about specific client needs related to turning?
Rationale:
Before delegating care, the nurse must ensure that they have collected relevant information
about the client's specific needs and preferences, especially given the complexity of end-stage

bone cancer. Understanding any limitations or special considerations is essential for safe and
effective care.
152. 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?
A. A prescribed consultation
B. The client’s vital signs
C. The client’s name
D. The client’s code status
Answer: D. The client’s code status
Rationale:
Assessment, Recommendation tool includes relevant clinical information that provides
context for the current situation. The client's code status is critical background information
that informs the receiving team about the client's wishes regarding resuscitation efforts and
overall treatment.
153. 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?
A. “I need some help planning my meals to maintain my weight.”
B. “I am tired of having pain in my joints all the time.”
C. “I’m having difficulty climbing the stairs at my house.”
D. “I will need assistance with bathing.”
Answer: D. “I will need assistance with bathing.”
Rationale:
Occupational therapists specialize in helping clients improve their ability to perform daily
activities and self-care tasks. The statement about needing assistance with bathing indicates
that the client may require strategies or adaptive equipment to manage personal care due to
physical limitations caused by rheumatoid arthritis.
154. 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?
A. Ask the adult neighbor to sign the consent form.
B. Obtain consent from the hospital administrator.
C. Witness the client signing the consent form.
D. Attempt to notify the client’s guardian to obtain consent.
Answer: D. Attempt to notify the client’s guardian to obtain consent.
Rationale:
In most jurisdictions, minors (typically individuals under 18 years of age) require parental or
guardian consent for medical procedures, including surgeries. Since the client is 16 years old,
the nurse must attempt to contact the guardian to obtain the necessary consent for the
appendectomy.
155. 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
Rationale:
A capillary refill time of 4 seconds indicates potential impaired perfusion or circulation,
especially after a cardiac catheterization. This is a concerning finding that may suggest
complications such as arterial occlusion or thrombus formation, which requires immediate
assessment and intervention.
156. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following
actions should the charge nurse take?
A. Assign clients who are not prescribed narcotics to the staff nurse.
B. Collect data about the staff nurse to support further action.
C. Report the staff nurse to the facility ethics committee.
D. Counsel the staff nurse about substance use.

Answer: B. Collect data about the staff nurse to support further action.
Rationale:
Before taking any formal action, it's essential for the charge nurse to gather objective data and
evidence regarding the staff nurse's behavior and performance. This can include observations
of the nurse’s interactions with clients, changes in behavior, or patterns that suggest
impairment.
157. 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?
A. “I will be given contrast dye during this test.”
B. “I might have to wear a nose clip during this test.”
C. “I might have a tube inserted into my airway during the test.’
D. “I will run on a treadmill during this test.”
Answer: B. “I might have to wear a nose clip during this test.”
Rationale:
Wearing a nose clip is a common practice during pulmonary function tests (PFTs), especially
during certain types of testing like spirometry, to ensure that all airflow is measured through
the mouth. This statement reflects an accurate understanding of the procedure.
158. A nurse in the emergency department is triaging four clients. Which of the following
clients should the nurse recommend to be examined first?
A. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood
B. An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from
0 to 10
C. An older adult client who has dyspnea and a respiratory rate of 26/min
D. An adult client who has large ecchymoses on both legs
Answer: C. An older adult client who has dyspnea and a respiratory rate of 26/min
Rationale:
The older adult client with dyspnea and a high respiratory rate is at risk for respiratory
failure, which is a critical condition that requires immediate attention. Dyspnea can indicate
underlying issues such as pneumonia, heart failure, or a pulmonary embolism, which can be
life-threatening.

159. 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?
A. Collaborating
B. Smoothing
C. Accommodating
D. Compromising
Answer: D. Compromising
Rationale:
• Both parties set aside their original individual goals work together to achieve a new
common goal.
• One party attempts to “smooth” another party by trying to satisfy the other party.
• One party scribes something, allowing the other party to get what it wants. This is the
opposite of competing. The original problem might not actually be resolved.
• Each party gives up something. To consider this a win/lose-win/lose solution, both parties
must give up something equally important. If one party gives up more than the other, it can
become a win-lose solution.
160. A nurse is planning to delegate client care assignments. Which of the following tasks
should the nurse plan to delegate to an assistive personnel?
A. Advising a client on self-administration of acetaminophen
B. Informing a family of a client’s progress in physical therapy
C. Teaching a client to perform a finger-stick for testing blood glucose levels RN
D. Performing post mortem care prior to transferring the client to the morgue
Answer: D. Performing post mortem care prior to transferring the client to the morgue
Rationale:
Performing post mortem care is a task that can be delegated to assistive personnel (AP). This
task does not require clinical judgment or assessment skills that a registered nurse (RN) must
perform.
161. A nurse is providing discharge teaching to a client following a total knee arthroplasty.
Which of the following information should the nurse include (SATA)
A. Advance directives information

B. Contact information for the physical therapist
C. Medication guidelines information
D. Insurance information
E. Information about follow-up care
Answer: B. Contact information for the physical therapist
C. Medication guidelines information
E. Information about follow-up care
Rationale:
• ATI MS 436 The client requires extensive physical therapy to regain mobility. The client
can be discharged home or to an acute rehabilitation facility. If discharged home, outpatient
or in‑home therapy must be provided. Home care should be available for 4 to 6 weeks.
• Provide medications as prescribed. Focus needs to be about pain medications. This
promotes client participation in early ambulation.
• Analgesics: Opioids (epidural, PCA, IV, oral), NSAIDs
• Peripheral nerve blockade: Inject the femoral or sciatic nerve with a local anaesthetic, or the
client can receive a continuous infusion of local anaesthetic directly into sciatic or femoral
nerve.
• A continuous peripheral nerve block provides localized pain relief.
• Monitor for systemic effects of local anaesthetic, such as metallic taste in the mouth,
tinnitus, slurred speech, decreased respiratory rate, hypotension, bradycardia, restlessness, or
seizure.
• Antibiotics: Prophylaxis is generally administered 30 min before the surgical incision is
made and postoperatively to prevent infection.
• Anticoagulant: Warfarin, fondaparinux, rivaroxaban, or low‑molecular‑weight heparin, such
as enoxaparin. The client can have a prescription for sequential compression devices, foot
pumps, and/or anti embolism stockings to prevent venous thromboembolism formation that
can develop into DVT. Always need to provide patient information about follow up care on
any post-op procedure.
162. 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?
A. “This service offers psychological interventions during and after your wife’s illness.”
B. “The clinicians help reduce the severity of your wife’s physical problems.”

C. “This service delivers meals and supplies to reduce your errands away from home.”
D. “It makes it possible for you to have some time away from caring for your wife.”
Answer: D. “It makes it possible for you to have some time away from caring for your wife.”
Rationale:
• Assist in removing or reducing factors that contribute to stress by referring caretakers of
older adult clients to respite services.
• Respite services are designed to provide temporary relief for caregivers, allowing them to
take breaks while ensuring that their loved ones continue to receive care. This response
directly addresses the partner's need for support and emphasizes the benefit of having time
away from caregiving duties.
163. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the
following instructions should the nurse include?
A. Warm the hands prior to piercing the skin.
B. Cap the lancet prior to putting it in the trash. - no capping
C. Elevate the arm for 1 min before taking the blood sample. - dependent position
D. Obtain the blood sample from the finger pads.
Answer: A. Warm the hands prior to piercing the skin.
Rationale:
• Massage or Warm fingers prior to piercing to promote blood flow in preparation for the
finger stick.
• Warming the hands before using a finger-stick glucometer can help increase blood flow to
the fingers, making it easier to obtain an adequate blood sample. This can enhance the
accuracy of the reading and minimize discomfort.
164. 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?
A. Receptive aphasia
B. Facial drooping
C. Memory loss
D. Unilateral neglect
Answer: D. Unilateral neglect
Rationale:
• Occupational Therapist- to learn how to perform ADLs.

• Unable to understand language in its written or spoken form
• Speech therapist
• It is one of the disabling features of stroke, and is defined as a failure to attend to the side
opposite a brain lesion.
165. 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 network for communication between staff members and families
B. A mental health specialist on the response team
C. A sufficient supply of personal protective equipment
D. A system for tracking client information
Answer: C. A sufficient supply of personal protective equipment
Rationale:
• ATI Community 66. Locate all equipment and supplies needed for disaster management,
including hazmat suits, infectious control items, medical supplies, food, and potable
(drinkable) water. Detail a plan to replenish these regularly.
• In a bioterrorism event, the first priority is ensuring the safety of healthcare workers and
responders. Personal protective equipment (PPE) is crucial for protecting staff from exposure
to potentially harmful biological agents.
166. 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. Rotavirus
B. Pertussis
C. Respiratory syncytial virus
D. Group B streptococcal disease
Answer: B. Pertussis
Rationale:
• ATI Community 64. National Notifiable Disease: Or Whooping cough
• Pertussis, also known as whooping cough, is classified as a reportable communicable
disease in many jurisdictions, including most states. This means that healthcare providers are
legally required to report cases to the health department to help monitor and control
outbreaks.

167. 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?
A. Chlorine bleach
B. Triclosan
C. Chlorhexidine
D. Isopropyl alcohol
Answer: A. Chlorine bleach
Rationale:
• Clostridium Difficile Spores are highly resistant to cleaning agents and will live for between
70-90 days outside the body and are only killed by cleaning agents containing Chlorine
Bleach.
168. 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. Treat and discharge the client.
B. Ask the client’s son to go to the waiting area.
C. File an incident report.
D. Ask the client about his injuries with the son present.
Answer: D. Ask the client about his injuries with the son present.
Rationale:
• Safety Measures: Priority.
• To assess for potential elder abuse effectively, the nurse should first speak with the client
alone. This allows the client to feel safe and be more open about any concerns or experiences
of abuse without the presence of the alleged abuser.
169. A nurse is completing discharge teaching with a client who is being treated for
tuberculosis (TB). Which of the following statements by the client indicates an understanding
of the teaching?
A. “I need to take my prescribed medication for 3 months.”
B. “I should have a sputum culture done every 2 to 4 weeks.”
C. “I need to have a TB skin test done once per year.”

D. “I should wear a mask while around my family.”
Answer: B. “I should have a sputum culture done every 2 to 4 weeks.”
Rationale:
• ATI MS. 138 Inform the client that sputum samples are needed every 2 to 4 weeks to
monitor therapy effectiveness. Clients are no longer considered infectious after three
consecutive negative sputum cultures, and may return to former employment.
• Clients being treated for tuberculosis (TB) need regular sputum cultures to monitor the
effectiveness of treatment and to determine when they are no longer infectious. This typically
occurs every 2 to 4 weeks during the initial phases of treatment.
170. 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?
A. Checking the pulses of the client’s right foot
B. Recording the client’s vital signs
C. Turning the client
D. Determining the client’s pain level
Answer: B. Recording the client’s vital signs
Rationale:

171. 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?
A. Inspect the skin of a newborn who is receiving phototherapy. – Assess
B. Answer the parents’ questions about newborn circumcision. - Teaching

C. Show a new mother how to change the newborn’s diaper. - Teaching
D. Obtain the weight of a newborn that is receiving formula
Answer: D. Obtain the weight of a newborn that is receiving formula
Rationale:
• Review table on #46.
• Weighing a newborn is a basic task that can be safely delegated to assistive personnel (AP).
It does not require specialized nursing knowledge or assessment skills.
172. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “A provider can write a prescription for restraints ‘as needed’.”
B. “I need to tie the restraint to the part of the bed frame that moves.”
C. “I should tie the restraints using a square knot.” - quick release
D. “I will remove a client’s restraints every 4 hours.”
Answer: B. “I need to tie the restraint to the part of the bed frame that moves.”
Rationale:
ATI Funda 59 ● Use a quick‑release knot to tie the restraints to the bed frame (loose knots
that are easy to remove) where they will not tighten when raising or lowering the bed. Assess
skin integrity, and provide skin care according to the facility’s protocol, usually every 2 hr.
• ATI Leadership 57 PRN Rx for restraints are NOT permitted.
• A provider's order for restraints must specify the duration and circumstances under which
they are to be used, but "as needed" (PRN) orders for restraints are not appropriate due to the
need for ongoing assessment and justification for their use.
173. 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?
A. Mumps
B. Rubeola
C. Varicella
D. Rotavirus
Answer: A. Mumps
Rationale:
• droplet

• measles
• airborne
• airborne
• contact
174. 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?
A. “Hospice care will prolong the life expectancy of clients who are terminally ill.”
B. “Hospice care is a multidisciplinary program for clients who are terminally ill.”
C. “Hospice care is helpful for clients at various stages of chronic illness.”
D. “Hospital access is no longer available for clients who are in hospice care.”
Answer: B. “Hospice care is a multidisciplinary program for clients who are terminally ill.”
Rationale:
Hospice care is designed for clients who are terminally ill and focuses on providing comfort,
pain relief, and support through a multidisciplinary team approach, including medical,
emotional, and spiritual care.
175. 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 assistive personnel?
A. Decide how often to measure vital signs.
B. Explain to the client about a 24-hr urine specimen collection.
C. Determine the client’s muscle strength prior to ambulation.
D. Remind the client to change positions slowly.
Answer: D. Remind the client to change positions slowly.
Rationale:
• Reminding a client to change positions slowly is a simple, non-invasive task that can be
delegated to assistive personnel (AP) without requiring specialized nursing judgment.
• This is an assessment task that requires nursing knowledge and should be done by a nurse.
176. 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?
A. Notify the risk management department of the situation.
B. Review with the nurse the principles of medication administration.
C. Ask the nurse to describe her medication administration procedure.

D. Identify education opportunities for the nurse regarding safe medication administration.
Answer: C. Ask the nurse to describe her medication administration procedure.
Rationale:
By asking the nurse to describe her medication administration procedure, the charge nurse is
assessing the nurse's understanding and identifying specific areas where errors may be
occurring. This step is crucial before taking further action.
177. 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? P. 42 ch 3
A. Libel
B. Battery
C. Slander
D. Negligence
Answer: A. Libel
Rationale:
• Talking bad about someone via writing it in notes
• Libel refers to a false statement that is written or published, causing harm to a person's
reputation. In this scenario, the progress report falsely identifies a client as HIV-positive,
which could significantly harm their reputation and social standing.
178. 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 bad 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.
Rationale:
Storing the ring in the facility safe ensures its safety and prevents loss during the surgical
procedure. Jewelry can be misplaced or damaged during surgery.

179. A nurse is prioritizing postpartum care for four clients. Which of the following actions
should the nurse take first?
A. Assist a client who requests help breastfeeding her 4-hr-old newborn.
B. Administer RH immune globulin to a client who is Rh-negative and 6 hr postpartum.
C. Check uterine tone for a client who received methylergonovine.
D. Instruct a client who has an episiotomy about a sitz bath.
Answer: C. Check uterine tone for a client who received methylergonovine.
Rationale:
Checking uterine tone is critical for assessing the risk of postpartum haemorrhage.
Methylergonovine is administered to help contract the uterus and prevent excessive bleeding,
so monitoring is essential.
180. 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. Withhold the benzodiazepine but continue the opioid. - not sure
B. Contact the provider about replacing the opioid with an NSAID.
C. Administer the benzodiazepine but withhold the opioid.
D. Continue the medication dosages that relieve the client’s pain.
Answer: A. Withhold the benzodiazepine but continue the opioid. - not sure
Rationale:
Opioids can cause respiratory depression, especially when combined with benzodiazepines. If
the client is somnolent and difficult to arouse, it's crucial to assess their respiratory status.
181. 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? Repeat
A. Administers the solution at room temperature
B. Points tubing in the direction of the umbilicus during insertion
C. Position the client on her left side with knees flexed
D. Inserts the tubing 8 cm (3.1 in) into the rectum
Answer: C. Position the client on her left side with knees flexed
Rationale:

While the left lateral position is generally appropriate for administering an enema, the nurse
should ensure that the client’s knees are comfortably flexed and that they are in a position that
allows for effective administration. If the AP is not ensuring comfort or proper positioning, it
should be addressed.
182. A nurse is providing information to a client about advance directives. The nurse should
explain that advance directives include which of the following?
A. Instructions regarding treatments the client desires or does not desire
B. Information regarding the disposition of the client’s body upon death
C. Information regarding organ donation
D. A form with directions for contacting next of kin
Answer: A. Instructions regarding treatments the client desires or does not desire
Rationale:
Advance directives are legal documents that allow individuals to outline their preferences for
medical treatment in the event they are unable to communicate those wishes themselves. This
includes specifying which treatments they do or do not want, such as resuscitation or
mechanical ventilation.
183. 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 has an absent pedal pulse in the right footABCS-absent pulse means
B. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy.
C. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38C (101F)
D. A client who is postoperative following a laminectomy 12 hr ago and is unable to void
Answer: A. A client who has peripheral vascular disease ad has an absent pedal pulse in the
right foot- ABCS-absent pulse means
Rationale:
• No Circulation is equal to necrosis it can make
• In this scenario, the client with an absent pedal pulse indicates a potentially critical
situation, as it suggests impaired blood flow to the extremity, which can lead to tissue

ischemia or necrosis. This is a high-priority issue that requires immediate assessment and
intervention.
184. 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? P . 36 ch 3
A. “In the role of client advocate, I should take responsibility for coordinating each client’s
care.”
B. “As a client advocate, I will suggest the best course of action for clients who are
indecisive.”- advocates assit them without control the situation.
C. “My role as a client advocate is to empower the clients to make informed healthcare
decisions.”
D. “As a client advocate, I will adhere to the provider’s prescribed treatments.”
Answer: C. “My role as a client advocate is to empower the clients to make informed
healthcare decisions.”
Rationale:
In the role of a client advocate, nurses aim to support and empower clients to understand their
options and make informed decisions about their care. This involves providing information,
answering questions, and ensuring that clients' rights and preferences are respected.
185. 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?
A. Refer the AP to the facility procedure manual.
B. Instruct the AP to request assistance when unsure about a task.
C. Help the AP assist the client with the transfer.
D. Demonstrate the proper client transfer technique for the AP.
Answer: C. Help the AP assist the client with the transfer.
Rationale:
When observing a potentially unsafe situation, the nurse’s immediate priority is to ensure the
safety and well-being of the client. By helping the AP with the transfer, the nurse can provide
immediate assistance and prevent any risk of injury to the client.

186. 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?
A. Chlamydia trachomatis
B. Pediculosis capitis
C. Impetigo contagious
D. Candida albicans
Answer: A. Chlamydia trachomatis
Rationale:
Chlamydia trachomatis is a reportable communicable disease in many jurisdictions due to its
prevalence and public health implications. Reporting helps track outbreaks and implement
necessary public health measures.
187. 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?
A. Escort the nurses to the nurses’ lounge to continue the discussion.
B. Recommend that both nurses be terminated.
C. Make arrangements to take over the client’s care.
D. Contact the house supervisor to mediate the conflict.
Answer: A. Escort the nurses to the nurses’ lounge to continue the discussion.
Rationale:
The charge nurse should address the inappropriate behavior of discussing sensitive issues
loudly at the nurses' station. By escorting the nurses to a more private setting, the charge
nurse ensures that the conversation remains confidential and professional. This action helps
maintain a respectful environment and allows for open communication about their concerns
regarding the client.
188. 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?
A. Accept the assignment with help from assistive personnel on the unit

B. Request that the charge nurse modify the assignment.- bring attention to the charge nurse
and negotiate ad new assignment , then take it up to chain of command , then file a
assignment despite objection .
C. Document the concern in the nurse’s notes.
D. Notify the risk manager.- you must follow chain of command, the first one to talk to is the
charge nurse.
Answer: A. Accept the assignment with help from assistive personnel on the unit
Rationale:
• Never Ever Accept An Assignment You Cannot Do! - prof katia told me in nursing ethics.
• If a newly licensed nurse feels unprepared or lacks experience for a specific assignment, the
safest course of action is to communicate this concern to the charge nurse. This allows for the
opportunity to modify the assignment to ensure patient safety and quality care. The nurse has
a responsibility to advocate for both their own capacity and their patients’ safety.
189. 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?
A. Recommending a referral for a client who requires physical therapy
B. Suggesting a client’s partner attend a support group for emotional support
C. Evaluating a client’s home for safety hazards
D. Completing an incident report following a medication error
Answer: A. Recommending a referral for a client who requires physical therapy
Rationale:
Advocacy in nursing involves supporting and promoting the needs and rights of clients.
Recommending a referral for physical therapy demonstrates advocacy by ensuring the client
receives the necessary care and resources for their recovery and well-being.
190. 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?
A. Administer IV nitro-glycerine to a client who is experiencing chest pain.
B. Perform a urinary catheterization for a client who has experienced a cerebrovascular
accident.
C. Set up a trauma room for an incoming client who was in a motor-vehicle crash.

D. Complete a SAD PERSONS assessment scale for a client who has attempted suicide.
Answer: B. Perform a urinary catheterization for a client who has experienced a
cerebrovascular accident.
Rationale:
Setting up a trauma room is a task that requires basic knowledge of emergency protocols and
equipment but does not require specific clinical skills or advanced knowledge that a float
nurse from a medical-surgical unit might not possess.
191. A home health nurse is assessing the home environment during an initial visit to a client
who has history of falls. Which of the following findings should the nurse identify as
increasing the client’s risk for falls? (SATA)
A. A folding chair without arm rests
B. A wheeled office chair at the client’s computer desk
C. A throw rug covering some cracked vinyl flooring in the kitchen
D. A two-wheeled walker used to assist the client with ambulation
E. A raised vinyl seat on the toilet in the bathroom
Answer: A. A folding chair without arm rests
B. A wheeled office chair at the client’s computer desk
C. A throw rug covering some cracked vinyl flooring in the kitchen
Rationale:
• This can be unstable and may not provide adequate support for the client when sitting down
or getting up, increasing the risk of falls.
• This type of chair can move easily and may cause instability, especially if the client tries to
get up without locking the wheels.
192. A nurse in a long-term care facility should identify that which of the following will
provide security for clients who have dementia?
A. Turning off room lights at night
B. Using a facility-wide paging system
C. Restricting space to reduce pacing
D. Setting alarms on exits
Answer: D. Setting alarms on exits
Rationale:

Setting alarms on exits helps ensure the safety of clients with dementia by alerting staff if a
resident attempts to leave the facility. This measure can prevent wandering and potential
harm.
193. 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.
D. Contact the client’s next of kin to obtain consent for treatment.
Answer: C. Proceed with treatment without obtaining written consent.
Rationale:
In emergency situations where a client is disoriented and unable to provide informed consent,
healthcare providers are allowed to proceed with treatment under the principle of implied
consent. This is based on the understanding that the client would consent to treatment if they
were able to do so.
194. 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?
A. Inform the nursing supervisor.
B. Notify the provider
C. Observe the client’s condition.
D. Complete an incident report.
Answer: C. Observe the client’s condition.
Rationale:
The immediate priority is to assess the client for any potential adverse effects or reactions
resulting from the additional dose of medication. Monitoring the client's condition will
provide crucial information to guide further actions.