Preview Extract
VERSION 2
ATI RN PROCTORED LEADERSHIP EXAM
A nurse manager is preparing to institute a new system for scheduling staff. Several
nurses have verbalized their concern over the possible changes that will occur. Which of
the following is an appropriate method to facilitate the adoption of the new scheduling
system?
A. Identify nurses who accept the change to help influence other staff nurses
B. Provide a brief overview of the new scheduling system immediately before it
implementation
C. Introduce the new scheduling system by describing how it will save the institution
money
D. Offer to reassign staff who do not support the change to another unit
Answer: B. Provide a brief overview of the new scheduling system immediately before
it implementation
A client who is febrile is admitted to the hospital for treatment of pneumonia. In
accordance with the care pathway, antibiotic therapy is prescribed. Which of the
following situations requires the nurse to complete a variance report with regard to the
care pathway?
A. Antibiotic therapy was initiated 2 hr after implementation of the care pathway
B. A blood culture was obtained after antibiotic therapy has been initiated
C. The route of antibiotic therapy on the care pathway was changed from IV to PO
D. An allergy to penicillin required an alternative antibiotic to be prescribed.
Answer: B. A blood culture was obtained after antibiotic therapy has been initiated
A nurse should recognize that an incident report is required when
A. A client refuses to attend physical therapy
B. A visitor pinches his finger in the client’s bed frame
C. A client throws a box of tissues at a nurse
D. A nurse gives a med 30 min late
Answer: A. A client refuses to attend physical therapy
Client satisfactory surveys from a med-surg unit indicate the pain is not being
adequately relieved during the first 12 hr post-opt. The unit manager decides to identify
post-opt pain as a quality indicator. Which of the following data sources will be helpful
in determine the reason why clients are not receiving adequate pain management after
surgery?
A. Prospective chart audit
B. Retrospective chart audit
C. Postoperative care policy
D. Pain assessment policy
Answer: D. Pain assessment policy
A nurse precepting a newly licenced nurse who is caring for a client who is confused
and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints
to prevent dislodging the IV catheter. Which of the following questions should the
precepting nurse ask?
A. “Did you secure the restraints to the side rails of the bed?”
B. “Are you able to insert two fingers between the restraint and the client’s skin?”
C. “Did you tie the restraints using double knot?”
D. “Are you removing the client’s restraints every 4 hr?”
Answer: B. “Are you able to insert two fingers between the restraint and the client’s
skin?”
A nurse is caring for an older adult client who has stage III pressure ulcer. The nurse
request a consultation with the wound care specialist. Which of the following actions by
the nurse is appropriate when working with a consultant?
A. Arrange the consultation for time when the nurse is caring for the client is able to be
present for consultation
B. Provide the consultant with subjective opinions and beliefs about the client’s wound
care
C. Request the consultation after several wound care treatment tried
D. Arrange for the wound care nurse specialist to see the client daily to provide the
recommended treatment
Answer: A. Arrange the consultation for time when the nurse is caring for the client is
able to be present for consultation
A client is admitted wit TB and placed in a negative pressure room. Which of the
following actions is appropriate?
A. Notify the local health department of the admission
B. Place a sign on the client’s door with the diagnosis
C. Ensure that admitting staff undergo PPD skin tests
D. Determine who had contact with the client in the last 48 hr
Answer: D. Determine who had contact with the client in the last 48 hr
A nurse is caring for a client who is unconscious and whose partner is health care proxy.
The partner has spoken with the provider and wishes to discontinue the client’s feeding
tube. The provider states the nurse, “I will not discontinue the client’s treatment. His
partner has no right to make decisions regarding the client’s care. “Which of the
following responses by the nurse is appropriate?
A. You should consider speaking with the facility’s ethics committee before making
your decision
B. You have the right to make decision, even if the partner is the client’s health care
proxy
C. The client has designated his partner as health care proxy in his advance directives
D. We’ll need to have the nursing supervisor review the client’s advance directives
Answer: C. The client has designated his partner as health care proxy in his advance
directives
A nurse is caring for a client who has increased intracranial pressure and is receiving IV
corticosteroids. Which of the following info is most important for the nurse to report at
shift change?
A. Gasglow Coma scale score
B. Most recent blood glucose reading
C. Lab test scheduled for next shift
D. Reddened area on the coccyx
Answer: A. Gasglow Coma scale score
A nurse is assigned the following four clients for the current shift. Which of the
following clients should the nurse assess first?
A. A client who has a hip fracture and is in Buck’s traction
B. A client who has aspiration pneumonia and a respiratory rate of 28/min
C. A client who has diabetes mellitus stage 2 pressure ulcer on his foot
D. A client who has a C diff infection and needs a stool specimen collected
Answer: D. A client who has a C diff infection and needs a stool specimen collected
A nurse is caring for a client who fell and is reporting pain in the left hip with external
rotation of the left leg. The nurse has been unable to reach the provider despite several
attempts over the past 30 min. Which of the following actions should the nurse take?
A. Notify the nursing supervisor about the issues
B. Contact the client’s physical therapist
C. Apply a warm compress to the hip
D. Reposition the client for comfort
Answer: A. Notify the nursing supervisor about the issues
The mother of a client with breast cancer states, it’s been hard for her, especially after
losing her hair. And it has been difficult to pay for all the treatments. Which of the
following actions is appropriate client advocacy?
A. The nurse investigates potential resources to help the client purchase wig
B. The nurse explains to the mother that most clients with cancer lose their hair
C. The nurse informs the next shift nurse regarding the mother’s concerns.
D. The nurse suggests counseling for the client’s body image issues
Answer: A. The nurse investigates potential resources to help the client purchase wig
Which of the following items must be discarded in a biohazard waste receptacle?
A. A urinary catheter drainage bag from a client who is post-opt
B. A bed sheet from a client with bacterial pneumonia
C. A perineal pad from a client who is 24-hr post-vaginal delivery
D. An empty IV bag removed from a client who has HIV
Answer: D. An empty IV bag removed from a client who has HIV
A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t
get better, I’m going to quit. “Which of the following responses appropriate?
A. “So you are upset about all the changes on the Unit”
B. “I think you have a right to be upset, I am tired of the changes too”
C. “Just stick with it a little longer. Things will get better soon
D. “ You should file complaints with hospital administrator
Answer: A. “So you are upset about all the changes on the Unit”
According to the HIPAA regulations, which of the following is a violation of client
confidentiality?
A. Telephone the pharmacy with a prescription for the spouse to pick up
B. Providing a copy of the record to the transporting paramedic
C. Reporting a client’s disposition to the referring provider
D. Informing housekeeping staff that the client is in dialysis unit
Answer: D. Informing housekeeping staff that the client is in dialysis unit
A Nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a
sterile procedure. Which of the following actions indicates the nurse is maintaining
sterile technique? (Select all that apply.)
A. Open the sterile pack by first unfolding the flap farthest from her body
B. Rests the cap of a solution container upside down on the sterile field
C. Removes the outside packaging of a sterile instrument before dropping into the
sterile field
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field
E. Places sterile items within 1.25 cm (0.5 inch) border around the edge of the sterile
field
Answer: A. Open the sterile pack by first unfolding the flap farthest from her body
C. Removes the outside packaging of a sterile instrument before dropping into the
sterile field
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field
A nurse is providing care for 4 post-opt clients. The nurse should first assess the client
A. Whose pulse has been steadily increasing during the past shift
B. Who is reporting a pain level of 8 on a scale of 0 to 10.
C. Whose urine output averaged 32 ml/hr for the past 24 hr
D. Who is reporting nausea after the prescribed antiemetic was administered
Answer: B. Who is reporting a pain level of 8 on a scale of 0 to 10.
A nurse is preparing to transcribe a client’s med prescription in the medical record.
Which of the following should the nurse recognize as containing the essential
components of a medication order?
A. NPH insulin 10 Units before and at bedtime
B. Haloperidol (Hadol) 1mg per mouth
C. Multivit every morning by mouth
D. Aspirin 650 mg by mouth every 4hr
Answer: D. Aspirin 650 mg by mouth every 4hr
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. Recommend that he takes time to plan at the beginning of shift
B. Advise him to complete less time-consuming tasks first
C. Ask other staff members to take over some of his staffs
D. Offer to provide care for his clients while he takes a break
Answer: A. Recommend that he takes time to plan at the beginning of shift
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. Remove the client’s clothing
B. Irrigate the exposed area with water
C. Report the incident to OSHA Don personal protective equipment.
Answer: B. Irrigate the exposed area with water
A facility provides annual staff education regarding ethical practice. A charge nurse
recognizes a need for further education when which of the following behaviors is
observed?
A. A nurse refuses to actively participate during an elective abortion procedure
scheduled for her client.
B. A nurse gives prescribed opioids to a client who has a terminal illness and
respirations of 8/min
C. A nurse explains to a client’s family that a DNR order includes withholding comfort
measures
D. A nurse informs a confused client who wants to go home that he is going to stay at
the facility until he is better
Answer: C. A nurse explains to a client’s family that a DNR order includes withholding
comfort measures
A nurse is an ambulatory care setting is orienting a newly licensed nurse who is
preparing to return a call to a client. The nurse should explain that which of the
following is an objective of tele health?
A. Assessing client needs
B. Providing med reconciliation
C. Establishing communication between providers
D. Developing client treatment protocols
Answer: C. Establishing communication between providers
Which of the following put a hospital at the highest risk of infringement of client record
confidentiality?
A. A nurse clusters documentation of care for multiple clients?
B. A provider and nurse access client info using one access code
C. Paper-based charts are stored at the nurse’s station
D. A nurse performs electronic documentation outside a client’s room
Answer: C. Paper-based charts are stored at the nurse’s station
Which of the following observations requires a charge nurse to intervene and
demonstrate safe handling techniques?
A. A nurse cleans up blood spill with a 1:10 bleach solution
B. A nurse uses googles to perform tracheostomy suctioning
C. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a
specimen
D. A nurse places a mask on a client with TB before transport to the radiology
department
Answer: C. A nurse disconnects an indwelling urinary catheter from the drainage bag to
collect a specimen
Which of the following should lead a nurse to suspect abuse that must be reported?
A. A school-age child has several bruises on her lower legs.
B. A toddler cries whenever his parents enters the hospitals room.
C. An Adolescent admitted to the emergency won’t speak to his parents
D. A preschool child who was previously toilet trained now requires diapers in the
hospital
Answer: B. A toddler cries whenever his parents enters the hospitals room.
A parish nurse is making 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. Liaison
B. Pastoral care provider
C. Health educator
D. Personal Health counselor
Answer: A. Liaison
A nurse performing triage during a mass casualty incident should recognize that which
of the following clients should be transported to the hospital first?
A. A client who reports substernal chest pain radiating to the neck
B. A client who has an open fracture of the femur
C. A client who has a 4-inch laceration on the forearm
D. A client who has a penetrating head injury and fixed dilated pupils
Answer: A. A client who reports substernal chest pain radiating to the neck
A nurse manager overhears a provider and a staff nurse talking about a client’s diagnosis
in the cafeteria. Which of the following actions should the nurse take first?
A. Provide a staff in-service about client confidentiality
B. Report the incident to the nursing supervisor
C. Remind them that the client info is confidential
D. Fill out an incident report regarding the situation
Answer: C. Remind them that the client info is confidential
A client has a substance use disorder is admitted to the mental health Unit and reports
that he has been depressed lately. When preparing for discharge the next day, the client
states: “It’s Ok. Soon everything will be just fine.” Which of the following is the nurse’s
primary first action?
A. Ask the client if he has considered hurting himself
B. Provide the client with info about Alcoholics Anonymous
C. Encourage the client to participate in physical activities
D. Reinforce the need to follow up with the discharge referral
Answer: A. Ask the client if he has considered hurting himself
A nurse is caring for a client who reports acute pain but refuses IM medication. The
nurse distracts the client and quickly administer the injection. This illustrate which of
the following?
A. False imprisonment
B. Battery
C. Assault
D. Libel
Answer: C. Assault
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. Report the situation to the director of nursing
B. Have a blood alcohol level drawn from the nurse
C. Document a factual description of the situation
D. Remove the nurse from the unit
Answer: D. Remove the nurse from the unit
A nurse observes a paper bag at the bedside of a client. This finding suggest that the
client is receiving treatment for which of the respiratory disorders
A. Asthma
B. Hyperventilation
C. Stidor
D. Atelectasis
Answer: A. Asthma
A nurse is preparing the discharge a client back to a long-term care facility after he was
admitted to an acute care facility 2 days ago for pneumonia. Which of the following
information should the nurse include in the verbal transfer report?
A. Lab results within the expected reference range
B. List of regularly prescribed meds
C. Date of last bowel movement
D. Level of consciousness
Answer: D. Level of consciousness
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. Review the client’s new lab values
B. Document assessment data
C. Complete required tasks
D. Determine client care goals
Answer: D. Determine client care goals
A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which
of the following statements by the newly licensed indicates understanding of isolation
guidelines?
A. I will instruct visitors to wear a mask when visiting a client who is on contact
precaution
B. I will place a client who has compromised immunity in a negative-pressure airflow
room
C. I will wear N-95respirator mask when caring for a client who is on droplet precaution
D. I will have a client who is on airborne precautions wear a mask when out of her room
Answer: D. I will have a client who is on airborne precautions wear a mask when out of
her room
A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks
is appropriate to delegate to a licensed practical nurse?
A. Changing the dressing on a postoperative wound
B. Referring a client to social services for assistance with transportation
C. Instructing a client who is obese about a low-fat diet
D. Providing the first oral feeding to a client following a stroke
Answer: A. Changing the dressing on a postoperative wound
A case manager working in a rehabilitation unit is discharging to home a client who a
spinal cord injury level C-7. Which of the following is the priority action creating the
discharge plan?
A. Select strategies for cost-effective home care
B. Identify the client’s ability to perform activities of daily living
C. Provide educational handouts related to care requirements.
D. Recommend community resources available to assist with client care.
Answer: B. Identify the client’s ability to perform activities of daily living
A nurse is preparing to complete morning assessments on several assigned clients.
Which of the following clients should the nurse plan to assess first?
A. A client who has a nasogastric tube to intermittent suction and reports nausea
B. A client who has an early morning blood glucose of 220 mg/dl
C. A client who had a bladder scan that indicated 250 ml of urine in the bladder
D. A client who is 3 days post-opt & whose dressing has serosanguinous drainage
Answer: D. A client who is 3 days post-opt & whose dressing has serosanguinous
drainage
A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
A. Plan break times for assistive personnel.
B. Pick up the meal trays after lunch.
C. Administer a nasogastric tube feeding.
D. Determine adequacy of ventilator settings
Answer: A. Plan break times for assistive personnel.
An RN is planning client assignments for a licensed practical nurse (LPN) and three
assistive personnel. The RN should assign the LPN to the client who requires
A. Recording of daily intake and output
B. Assistance with meals
C. A complete bed bath
D. Frequent dressing changes
Answer: D. Frequent dressing changes
A nurse is caring for 4 clients. Which of the following tasks can be delegated to an
assistive personnel?
A. Assessing a client who just returned from hemodialysis
B. Reviewing dietary instructions for a client with kidney stones
C. Obtaining a stool sample from a client with renal failure
D. Monitoring a client with a fluid restriction
Answer: C. Obtaining a stool sample from a client with renal failure
A charge nurse is 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. Remove the restraints from the client’s wrists.
C. Speak with the AP about the incident
D. Review the chart for non-restraint alternatives for agitation.
Answer: B. Remove the restraints from the client’s wrists.
A client is brought to the emergency department (ED) following a motor-vehicle creash.
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. Document the client’s refusal in the chart
B. Tell the client that a catheter will be inserted
C. Obtain a provider’s prescription for a blood alcohol level.
D. Assess the client for urinary retention.
Answer: A. Document the client’s refusal in the chart
Nurses on an impatient 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. Wait to dispose of sharps containers until they are completely full.
C. Return unused supplies from the bedside to the unit’s supply stock.
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.
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. Turning the client
B. Recording the client’s vital signs
C. Determining the client’s pain level
D. Checking the pulses of the client’s right foot.
Answer: B. Recording the client’s vital signs
To resolve a conflict between staff members regarding potential changes in policy, a
nurse manager decides to implement the changes she prefers regardless of the feelings
of those who oppose those changes. Which of the following conflict-resolution
strategies in the nurse manager using?
A. Compromising
B. Collaborating
C. Cooperating
D. Competing
Answer: D. Competing
A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the
following clients should be assigned to an RN who has floated from a medical-surgical
unit?
A. A client who has gestational diabetes and is receiving biweekly nonstress tests
B. A primigravida client who is 1 day post-opt following a caesarean section and has a
PCA pump
C. A multigravida client who has preeclampsia and is receiving misoprostol (Cytotec)
for induction of labor.
D. A client who is at 32 weeks of gestation and has premature rupture of membranes.
Answer: A. A client who has gestational diabetes and is receiving biweekly nonstress
tests
A nurse working on a medical-surgical unit is managing the care of 4 clients. The nurse
should schedule an interdisciplinary conference for which of the following clients?
A. A client who is at risk for pressure ulcers and has an albumin of 4.2 g/dl
B. A client who has type 1 DM and uses insulin pump
C. A client who has orthostatic hypotension and is receiving IV fluids.
D. A client who is receiving heparin and has an aPTT of 34 seconds
Answer: D. A client who is receiving heparin and has an aPTT of 34 seconds
A charge nurse is assessing staff knowledge about safety procedures regarding
needlestick injuries. Which of the following statements by a nurse indicates appropriate
understanding of these safety procedures?
A. Prophylactic treatment should be initiated after a needlestick during preparation of an
injection
B. I should stop the bleeding as soon as possible following a needlestick injury
C. An incident report should be completed if a client receives a stick from her own used
needle
D. The needle should be recapped to prevent injury during transport to the biohazard
container.
Answer: A. Prophylactic treatment should be initiated after a needlestick during
preparation of an injection
A nurse on a medical surgical Unit is caring for a group of clients with the assistance of
a licensed practical nurse (LPN) and an assistive personnel. Which of the following taks
should the nurse assign to the LPN
A. Obtaining a urine specimen from an older adult client
B. Providing postmortem care for a client who has just died
C. Accompanying a client who just had a wound debridement to physical therapy
D. Reinforcing dietary teaching with a client who has heart disease
Answer: C. Accompanying a client who just had a wound debridement to physical
therapy
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 info about his mother’s condition
B. Complete an incident report regarding the breach of the client’s confidentiality
C. Log out of the computer so that the client’s son is unable to view his mother’s info
D. Report the possible violation of client confidentiality to the nurse manager
Answer: C. Log out of the computer so that the client’s son is unable to view his
mother’s info
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 oxygen machine has a grounded plug
B. The family keeps a spare oxygen tank in the room
C. The window of the client’s room are open
D. The client is covered with a woollen blanket
Answer: A. The oxygen machine has a grounded plug
Rationale:
Oxygen therapy safety precaution: Avoid materials that generate static electricity, such
as woollen blankets and synthetic fabrics. Advise clients and caregivers to wear cotton
fabrics and use cotton blankets.
A nurse is teaching a client how to use a finger stick glucometer at home. Which of the
following instruction should the nurse include?
A. Elevate the arm for 1 min before taking the blood sample
B. Cap the lancet prior to putting it in in the trash
C. Obtain the blood sample from the finger pads.
D. Warm the hands prior to piercing the skin
Answer: C. Obtain the blood sample from the finger pads.
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. Contact the client’s next of kin to obtain consent for treatment.
B. Proceed with treatment without obtaining written consent
C. Have the client sign a consent for treatment.
D. Notify risk management before initiating treatment.
Answer: A. Contact the client’s next of kin to obtain consent for treatment.
A client has a new permanent pacemaker inserted. Which of the following home care
instructions should the nurse include?
A. The client should avoid using microwave oven to heat food
B. Regular programming evaluations can be conducted by telephones
C. The client should avoid using remote control devices to prevent dysrhythmias
D. Suctioning could cause the unit to have an electrical shock.
Answer: A. The client should avoid using microwave oven to heat food
B. Regular programming evaluations can be conducted by telephones
While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that 6 of the 15 records lack documentation regarding advance directives.
Which of the following is the priority action for the nurse to take?
A. Reinforce the potential consequences of not having this info on record to the nursing
staff.
B. Ask the nurses who are caring for clients without this info in the medical record to
obtain it.
C. Meet with nursing staff to review the policy regarding advance directives.
D. Remind nurses to obtain this info during the admission process.
Answer: B. Ask the nurses who are caring for clients without this info in the medical
record to obtain it.
A client is admitted with COPD. Which of the following findings should the nurse
report to the provider?
A. Oxygen saturation 89% on room air.
B. WBC’s count 9,000/mm
C. Report of dyspnea on exertion
D. Bilateral crackles on auscultation of lungs.
Answer: D. Bilateral crackles on auscultation of lungs.
A charge nurse notices 2 staff nurses are not taking meal breaks during 8-hr shifts.
Which of the following actions should the nurse take first?
A. Provide coverage for the nurse’s breaks.
B. Determine the reasons the nurses are not taking scheduled breaks.
C. Discuss tie management strategies with the nurses.
D. Review facility policies for taking scheduled breaks.
Answer: B. Determine the reasons the nurses are not taking scheduled breaks.
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. Occupational therapist
B. Nutritional therapist
C. Physical therapist
D. Mental Health counselor
E. Case manager
Answer: B. Nutritional therapist
D. Mental Health counselor
E. Case manager
A nurse manger 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. Guardian consent is required for an emancipated minor
B. Consent can be given by a durable power of attorney.
C. A family member can answer any questions the client has about the procedure.
D. The nurse can answer any questions the client has about the procedure
Answer: A. Guardian consent is required for an emancipated minor
A nurse on a medical-surgical unit is caring for 4 clients. This nurse should recognize
that which of the following clients is the highest priority?
A. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy.
B. A client who has peripheral vascular disease and has absent pedal pulse in right foot.
C. A client who is post-opt following a laminectomy 12 hr ago and is unable to void.
D. A client who has methicillin-resistant Staphylococcus Aureus (MRSA) and has an
axillary temp of 38 degree C (101 F)
Answer: B. A client who has peripheral vascular disease and has absent pedal pulse in
right foot.
A client scheduled for a tubal ligation procedure starts to cry as she 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. This won’t take long and it will be over before you know it.
C. Why did you make the decision to have this procedure
D. You shouldn’t be worried because the procedure is very safe
Answer: A. It’s not too late to cancel the surgery if you want to
A nurse working in the emergency department is assessing several clients. Which of the
following clients is the highest priority?
A. A client who has a raised red skin rash on his arms, neck, and face
B. A client who reports right-sided flank pain and is diaphoretic
C. A client who reports shortness of breath and left neck and shoulder pain
D. A client who has active bleeding from a puncture wound of the left groin
Answer: C. A client who reports shortness of breath and left neck and shoulder pain
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 of the quality improvement process?
A. Review current literature regarding client falls.
B. Implement a fall prevention plan
C. Notify staff of the increased fall rates
D. Identify clients who are at risk for falls
Answer: D. Identify clients who are at risk for falls
A nurse is evaluating a newly licensed nurse who is administering a vitamin K
(Aquamephytoin) injection to a newborn. Which of the following actions by the newly
licensed nurse indicates understanding of the teaching? (Select all that apply.)
A. Selects the dorsogluteal site to administer the injection
B. Cleans the injection site with alcohol
C. Applies gentle pressure at the site after injection
D. Aspirate the syringe for blood return after needle insertion
E. Inserts the needle at a 45 degree angle.
Answer: B. Cleans the injection site with alcohol
C. Applies gentle pressure at the site after injection
A nurse enters a client’s room and observes a fire in a trash can. Identitfy, the sequence
of actions the nurse should take. (Move all the actions into the box on the right, placing
them in the selected order 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: Correct Sequence order is
B. Activate the fire alarm system
C. Confine the fire by closing doors and windows
A. Remove the client from the area
D. Extinguish the fire if possible
Which of the following actions taken by a nurse constitutes battery?
A. Failing to put up side rails on a confused client’s bed
B. Telling a client who refused his oral medication that he will be given an injection
C. Inserting a feeding tube against the wishes of a client who refuses to eat
D. Threatening to apply wrist restraints to control a client who is agitated
Answer: C. Inserting a feeding tube against the wishes of a client who refuses to eat
VERSION 3
ATI RN PROCTORED LEADERSHIP EXAM FORM A
A charge nurse for the emergency department is supervising a nurse who has been
temporarily reassigned from the medical-surgical unit during a busy time. Which of the
following assignments is most appropriate for this nurse?
A. Obtaining a medical history from a client who attempted suicide
B. Collecting a catheter urine specimen from a 2-year-old child with a fever
C. Setting up a trauma room for an incoming motor-vehicle crash victim
D. Performing triage for three clients who have just arrived in the waiting area
Answer: B. Collecting a catheter urine specimen from a 2-year-old child with a fever
A nurse should first provide care for which of the following clients?
A. An older adult with dyspnea and a respiratory rate of 22/min
B. A toddler who has a head laceration oozing dark red blood
C. An adult client with large ecchymoses on both legs
D. An adolescent with an injured ankle and pain rated at 10 on a 0-10 scale
Answer: B. A toddler who has a head laceration oozing dark red blood
A client with methicillin-resistant Staphylococcus aureus (MRSA) of the urine is being
admitted into the hospital and is placed on contact isolation. Which of the following
should cause the charge nurse to intervene?
A. The client is dressed in an isolation gown for transport to x-ray.
B. The door for the isolation room is left open.
C. A nurse checks the client's IV without wearing gloves.
D. A provider uses alcohol-based hand cleanser after providing care.
Answer: C. A nurse checks the client's IV without wearing gloves
A nurse is caring for a competent client who is newly diagnosed with a terminal illness.
Which of the following statements by the client indicates a correct understanding of
advance directives?
A. "From this point on, my partner has control over my health care decisions."
B. "I am so relieved that the decisions about my care are finalized."
C. "I'm glad that the doctors now can make all the final decisions."
D. "When I can no longer make decisions, people now know what I want."
Answer: D. "When I can no longer make decisions, people now know what I want."
A client who is intoxicated presents to the emergency department and reports struggling
with depression lately. The next day, the client is ready for discharge and states, “It’s
okay. Soon everything will be just fine.” Which of the following is the nurse's priority
action?
A. Ask the client if he is feeling suicidal.
B. Remind the client that change is always possible.
C. Inquire about the client's regular alcohol consumption.
D. Reinforce the need to follow up with the discharge referral.
Answer: A. Ask the client if he is feeling suicidal
A client diagnosed with an inferior MI 2 days ago suddenly reports nausea and
midsternal chest pain. After ensuring that oxygen support is patent, which of the
following interventions should the nurse anticipate taking next?
A. Assess for S3 heart sounds.
B. Administer a prescribed antiemetic.
C. Notify the primary care provider.
D. Obtain a 12-lead ECG.
Answer: D. Obtain a 12-lead ECG
The staff on an orthopaedic unit have implemented a plan to prevent loss of revenue
from supply and equipment charges. Which of the following indicates that the plan is
successful?
A. Supplies for dressing changes are kept at the bedside.
B. Billing for the unit has increased in the last quarter.
C. Unused supplies from discharged clients are saved for future use.
D. Documentation of the supplies used for each client is complete.
Answer: D. Documentation of the supplies used for each client is complete
A nurse working in an emergency department has been assigned four clients. Which of
the following client conditions should be reported to the appropriate authorities?
A. A female client with deep bruising to her lower leg
B. An adolescent client with Clostridium difficile
C. An older adult client with a stage I pressure ulcer
D. A male client with a bite from an unknown dog
Answer: D. A male client with a bite from an unknown dog
A nurse is caring for an older adult client with type 1 diabetes mellitus and a stage II
ulcer on his left leg. The client’s medical history indicates that he drinks a pint or two of
vodka each day. Which of the following should the nurse include in the client’s plan of
care?
A. Coordinate a referral to an outpatient alcohol treatment center.
B. Involve the family in confronting the client about his alcoholism.
C. Teach the family how to monitor and control the client’s alcohol intake.
D. Provide strategies to assist the client in moderating his alcohol intake.
Answer: A. Coordinate a referral to an outpatient alcohol treatment center
A nurse is assigned a non-English speaking client who is scheduled for surgery. Which
of the following is the appropriate method for obtaining informed consent from the
client?
A. Use a professional interpreter.
B. Request that a family member act as a translator.
C. Ask a bilingual nurse on the unit to assist the client.
D. Provide the consent document in the client's native language.
Answer: A. Use a professional interpreter
When planning for updates on infection control, fire and safety, and confidentiality
issues, which of the following methods of educational delivery is most efficient?
A. Classes available monthly by the staff development educators
B. Day-long training sessions available twice a year
C. Each unit providing classes at shift changes
D. Self-directed computer-based modules with post tests
Answer: D. Self-directed computer-based modules with post tests
A charge nurse is assessing staff knowledge about safety procedures regarding needle
stick injuries. Which of the following statements by a nurse indicates appropriate
understanding of these safety procedures?
A. "Prophylactic treatment should be initiated after a needle stick during preparation of
an injection."
B. "I should stop the bleeding as soon as possible following a needle stick injury."
C. "An incident report should be completed if a client receives a stick from her own
used needle."
D. "The needle should be recapped to prevent injury during transport to the biohazard
container."
Answer: C. "An incident report should be completed if a client receives a stick from her
own used needle."
A nurse at a long-term care facility is planning a fall prevention program for the
residents. Which of the following should be included in the plan?
A. Keep the four side rails up on beds at night.
B. Apply vest restraints on residents who are confused.
C. Accompany residents older than 85 during ambulation.
D. Institute rounds every 2 hr during the day to offer toileting.
Answer: D. Institute rounds every 2 hr during the day to offer toileting
A nurse is providing discharge instructions to a client who had a mastectomy and is
going home with a drain. Which of the following statements is appropriate to include in
the instructions?
A. "Begin performing stretching exercises the day after you get home."
B. "Keep the incision dry until the stitches are removed."
C. "Notify the primary care provider if there is numbness at the surgical site."
D. "Follow a low-sodium diet to prevent lymphedema."
Answer: B. "Keep the incision dry until the stitches are removed."
A client is admitted to the hospital and makes end-of-life care decisions prior to the
arrival of her family. The family arrives and asks the nurse to change the client's mind
regarding end-of-life care. Which of the following actions should the nurse take?
A. Facilitate a meeting with the client and the family.
B. Have the family meet with the primary care provider.
C. Request a social service consult for the client and family.
D. Inform the family that the client's decisions are final.
Answer: A. Facilitate a meeting with the client and the family.
A nurse who is caring for clients on the medical-surgical unit delegates collection of
vital signs to an assistive personnel (AP). Which of the following nursing actions is
important in ensuring safe client care?
A. The nurse looks at vital sign trends at the end of the shift.
B. The nurse rechecks an abnormal blood pressure measurement.
C. The nurse asks the AP to report any unusual findings.
D. The nurse accompanies the AP during vital sign collection.
Answer: B. The nurse rechecks an abnormal blood pressure measurement.
A nurse working in a rehabilitation facility is caring for a client with paraplegia from a
spinal cord injury. An interdisciplinary team is scheduled to meet and discuss the client's
needs. Which of the following concerns is the highest priority for the nurse to report to
the team?
A. The client has experienced a decrease in appetite.
B. The client lives alone in a second-story apartment.
C. The client has a stage I pressure ulcer on his heel.
D. The client reports fatigue during occupational therapy.
Answer: C. The client has a stage I pressure ulcer on his heel
An RN is planning client assignments for an assistive personnel (AP). The RN should
assign the AP to the care of a client who requires:
A. Assessment of nasogastric tube output.
B. Feeding due to difficulty swallowing after a stroke.
C. Help with bathing and toileting following hip surgery.
D. Colostomy irrigations and bag changes.
Answer: C. Help with bathing and toileting following hip surgery
A disaster is occurring, and the charge nurse on a medical-surgical unit must determine
which clients can be discharged. Which of the following clients should the nurse
recommend for discharge?
A. A client with a troponin level of 3 ng/mL.
B. A client with a deep vein thrombosis and an INR of 2.0.
C. A client who is 1 day postoperative following gastrectomy.
D. A client who reports numbness on the left side of the face.
Answer: B. A client with a deep vein thrombosis and an INR of 2.0
A charge nurse suspects that a staff nurse has a problem with opioid abuse. Which of the
following is the appropriate action for the nurse to take?
A. Assign clients who are not prescribed opioids to the nurse.
B. Collect data to support further action.
C. Arrange for another nurse to witness the nurse administer opioids.
D. Report the nurse to the state board of nursing.
Answer: B. Collect data to support further action
An RN has just received report for four clients. The nurse should plan to first assess the
client who:
A. Has pain uncontrolled by PCA morphine.
B. A newly discovered non-blanching reddened area on the right hip.
C. A nonpatent gastric tube used for bolus feedings.
D. Refused to go for a scheduled gastrointestinal diagnostic procedure.
Answer: A. Has pain uncontrolled by PCA morphine
A nurse is preparing to witness the informed consent of a client who is to undergo a
gastrectomy. The client has a question regarding the post operative diet. Which of the
following should the nurse do?
A. Review the surgeon's instructions regarding the procedure.
B. Reassure the client that there will be time to review the diet after surgery.
C. Notify a registered dietician and have her explain the diet to the client.
D. Answer the question and have the client sign the surgical permit.
Answer: C. Notify a registered dietician and have her explain the diet to the client
On admission, a female client who is Muslim tells the female charge nurse that she
wants only female nurses to provide her care. Which of the following actions should the
charge nurse take first?
A. Consult with the nursing supervisor.
B. Explain that clients are not allowed to pick caregivers.
C. Explore the basis for this request with the client.
D. Provide the client's care herself.
Answer: C. Explore the basis for this request with the client
A triage nurse in an emergency department should assign priority to a client arriving
with:
A. A laceration of the right index finger with profuse bleeding.
B. Sudden onset of left-sided paralysis and slurred speech.
C. Severe vomiting and diarrhea with dehydration.
D. A burn of the right lower forearm with significant edema and blistering.
Answer: B. Sudden onset of left-sided paralysis and slurred speech
A fire is discovered in the hospital, and the charge nurse has orders to evacuate. Which
of the following clients should be evacuated first?
A. A client who is in Buck's traction for a left hip fracture.
B. A client who is 1 day post thoracic surgery with a chest tube.
C. A client who is confused and restrained for safety.
D. A client who is ambulatory and receiving an infusion of chemotherapy.
Answer: D. A client who is ambulatory and receiving an infusion of chemotherapy
A client is brought to the emergency department (ED) 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. Document the client's refusal in the chart.
B. Tell the client that a catheter will be inserted.
C. Keep the client in the ED until a specimen is provided.
D. Assess the client for urinary retention.
Answer: A. Document the client's refusal in the chart
A primary care provider recommends surgery for a client with a tumor. The client is
refusing, but the spouse wants the surgery performed. Which of the following is the
deciding factor in determining if the surgery will be done?
A. Whether the spouse is the client's durable power of attorney for health care.
B. Whether the client's refusal is based on religious belief.
C. Whether the client understands the risk of refusing the procedure.
D. Whether the facility ethics committee reaches a consensus on the case.
Answer: C. Whether the client understands the risk of refusing the procedure
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. Use an alcohol pad at the site after taking the sample.
B. Cap the lancet prior to putting it in the trash.
C. Obtain the sample from the finger pads.
D. Warm the hands prior to taking the blood sample.
Answer: D. Warm the hands prior to taking the blood sample
A nurse notes a new prescription in a client's medical record for oral digoxin (Lanoxin)
2.5 mg to be given daily. The nurse questions the dosage of the prescription, and the
provider confirms the dosage as written. Which of the following responses by the nurse
is appropriate?
A. Verify that the client's apical pulse is greater than 60/min.
B. Check the client's serum digoxin and potassium levels.
C. Hold the medication and contact the nursing supervisor.
D. Request an order for telemetry monitoring.
Answer: C. Hold the medication and contact the nursing supervisor
A case manager is caring for an older adult client with type 1 diabetes mellitus, chronic
renal failure, and limited visual acuity. The client lives alone and has children who visit
infrequently. Which of the following should the case manager recognize as the highest
priority consideration?
A. Nutritional resources
B. Financial assistance
C. Medication monitoring
D. Housekeeping assistance
Answer: C. Medication monitoring
A nurse is caring for a client who sustained multiple injuries in a motor vehicle crash,
which was reported in the local newspaper. A newspaper reporter calls for an update on
the client's condition. The nurse tells the reporter that the client has had surgery and is
stable. The nurse has committed an act of:
A. Slander.
B. Libel.
C. Will-full neglect.
D. Invasion of privacy.
Answer: D. Invasion of privacy
A charge nurse overhears an exchange between a client and a staff nurse. Which of the
following statements by the staff nurse indicates a need for further education on client
rights?
A. "I can't discuss with you the medical care of the client in the next bed."
B. "You shouldn't read your medical chart because you won't understand the
terminology."
C. "You cannot be transferred to your preferred facility until we are notified that there is
space available."
D. "I will request a list of the hospital's charges for services for you to review."
Answer: B. "You shouldn't read your medical chart because you won't understand the
terminology."
A nurse receives report on four clients. Which of the following clients should the nurse
attend to first?
A. A client admitted this morning with unstable angina
B. A client who vomited once at the end of the last shift
C. A client who has an Hgb of 7 g/dL and an Hct of 26%
D. A client who is currently trying to climb out of bed
Answer: D. A client who is currently trying to climb out of bed
A nurse on an orthopaedic unit is assigned to work with a new assistive personnel (AP).
The AP is delegated the task of transferring a client with a knee replacement from the
bed to a chair. Which of the following is the most appropriate method of ensuring the
new AP can perform the action safely?
A. Teach proper technique for this skill to the AP.
B. Ask the AP if he has prior experience with this skill.
C. Review the AP's skills checklist.
D. Watch the AP demonstrate the skill.
Answer: D. Watch the AP demonstrate the skill
During discharge teaching, a nurse learns that a client does not have transportation for a
follow-up appointment with the primary care provider. Which of the following is the
most appropriate action by the nurse?
A. Provide the client with information regarding public transportation.
B. Refer the client to a social worker for transportation options.
C. Call the primary care provider to reschedule the appointment.
D. Encourage the client to seek transportation from family after discharge.
Answer: B. Refer the client to a social worker for transportation options
The husband and children of an older adult female client are expressing conflict over
whether the client should receive surgery that is recommended by the primary care
provider. The oldest son has durable power of attorney for health care for both his
mother and father. The client is oriented to person, place, and time. Which of the
following people has the legal authority to make this health care decision?
A. The husband
B. The oldest son
C. The primary care provider
D. The client
Answer: D. The client
A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
A. Assessing a client who just returned from hemodialysis
B. Reviewing dietary instructions for a client with kidney stones
C. Obtaining a stool sample from a client with renal failure
D. Monitoring a client with a fluid restriction
Answer: C. Obtaining a stool sample from a client with renal failure
A charge nurse on a medical-surgical unit is responsible for supervising the care
provided by the unit staff. Which of the following is the most effective method for
determining the learning needs of the unit staff?
A. Ask unit staff to complete a skills checklist.
B. Require attendance at annual competency updates.
C. Perform direct observation of provided care.
D. Implement a peer review process on the unit.
Answer: C. Perform direct observation of provided care
A charge nurse notices that two staff nurses take no breaks during their regular 8-hr
shifts. Which of the following should the charge nurse plan to do?
A. Give them overtime pay for the break times.
B. Ensure coverage for enforced break times.
C. Assign the two staff nurses the same break times.
D. Allow them to take their breaks while charting.
Answer: B. Ensure coverage for enforced break times
A staff nurse reports for a regularly scheduled shift and finds that the unit is short of
staff. The charge nurse insists that the nurse care for five clients who are high acuity
despite the staff nurse's objections. Which of the following actions should the staff nurse
take?
A. Care for the five clients as best as possible.
B. Delegate initial shift assessments to assistive personnel.
C. Call nurses from the float pool to report to the unit.
D. Notify the nurse manager of the situation.
Answer: D. Notify the nurse manager of the situation
A client with a draining foot ulcer is being prepared for discharge home with the family.
The nurse observes another nurse changing the client's wound dressing. Which of the
following actions requires intervention to maintain safe handling of contaminated
material?
A. The old dressing is placed on a nearby table.
B. Gloves are discarded after removing the old dressing.
C. Sterile supplies are opened prior to the procedure.
D. The wound is irrigated into a clean basin.
Answer: A. The old dressing is placed on a nearby table.
A nurse is assigned four clients. Which of the following client needs takes priority?
A. A client’s intravenous site has infiltrated.
B. A client’s capillary blood glucose is 250 mg/dL.
C. A client reports a frontal headache rated at 7 out of 10.
D. A client is refusing a scheduled nebulizer treatment.
Answer: A. A client’s intravenous site has infiltrated.
A client had a cerebrovascular accident (stroke) 2 days ago. Which of the following
assessments should a nurse recognize as indicating a need for a referral to a speech and
language pathologist?
A. Altered level of consciousness
B. Unilateral facial drooping
C. Persistent coughing while drinking
D. Left-sided hemiparesis
Answer: C. Persistent coughing while drinking
A nurse in an outpatient clinic is taking a medical history on a new client. The client
takes multiple medications each day but cannot remember the names. Which of the
following is the most appropriate response by the nurse?
A. "What is the name and phone number of your primary doctor?"
B. "You should make a list of all your medications for future use."
C. "Next time you come to the clinic, bring the medications with you."
D. "What conditions are you taking medications for?"
Answer: C. "Next time you come to the clinic, bring the medications with you."
A nurse manager wants to implement a new safety program. Which of the following
actions will best facilitate the program’s success?
A. Indicate that the change is mandatory.
B. Offer rewards to staff members who comply.
C. Involve staff in planning its implementation.
D. Tell staff to report problems to management.
Answer: C. Involve staff in planning its implementation.
A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
A. Plan break times for assistive personnel.
B. Pick up the meal trays after lunch.
C. Administer a nasogastric tube feeding.
D. Determine adequacy of ventilator settings.
Answer: C. Administer a nasogastric tube feeding.
A new graduate nurse is taking a telephone medication order from a primary care
provider and is having difficulty hearing the provider's prescription. Which of the
following is the most appropriate action by the nurse?
A. Repeat the order back to the provider.
B. Ask the charge nurse to take the order.
C. Consult the pharmacist for clarification.
D. Ask the provider to come write the order.
Answer: D. Ask the provider to come write the order.
A nurse enters an adolescent’s room after some visiting classmates leave. The nurse
notes a small fire in the client’s waste paper basket. Which of the following is the
nurse’s priority action?
A. Use the client’s telephone to report the fire.
B. Assist the client out of the area immediately.
C. Cover the waste paper basket with a bedpan.
D. Use the nearest fire extinguisher to put out the fire.
Answer: B. Assist the client out of the area immediately.
An older adult client with terminal cancer is brought to the emergency department with
acute pneumonia. The client has a valid living will that indicates comfort measures only
should be used. Which of the following is appropriate to include in the client's plan of
care based on the living will?
A. Titrate oxygen to maintain an oxygen saturation of 92%.
B. Prepare the client for IV dopamine (Intropin) to maintain blood pressure.
C. Administer oral chemotherapy to the client.
D. Contact the immediate family for care-giving decisions.
Answer: A. Titrate oxygen to maintain an oxygen saturation of 92%.
A charge nurse notices that staff nurses are having difficulty using new IV pumps for
medication administration. Which of the following actions by the charge nurse is most
appropriate?
A. Contact the staff education department for an in-service for the staff.
B. Assume responsibility for IV medication administration during the shift.
C. Instruct the staff nurses to administer IV medications without the pumps.
D. Request assistance from the nursing supervisor.
Answer: A. Contact the staff education department for an in-service for the staff.
Which of the following actions taken by a nurse constitutes battery?
A. Failing to put up side rails on a confused client's bed
B. Telling a client who refused his oral medication that he will be given an injection
C. Inserting a feeding tube against the wishes of a client who refuses to eat
D. Threatening to apply wrist restraints to control a client who is agitated
Answer: C. Inserting a feeding tube against the wishes of a client who refuses to eat
A visiting nurse is evaluating the home environment of an older adult client. Which of
the following should the nurse recognize as an environmental hazard?
A. The house has a short staircase covered with plush carpet.
B. There is a household pet that wears a bell around its neck.
C. Papers are scattered on the floor throughout the living room.
D. The curtains in living areas are closed during the day.
Answer: C. Papers are scattered on the floor throughout the living room.
A client states she will go home alone following her left hip pinning surgery. The most
appropriate action for the nurse to take is to
A. chart the client’s comment in the medical record.
B. contact the case manager for a consultation.
C. call the primary care provider and report this information.
D. use therapeutic communication to help the client verbalize her concerns.
Answer: B. contact the case manager for a consultation.
A nurse finds a client lying on the floor of his hospital room. The client states that he
slipped off the commode while trying to sit down. The client has no injuries and is
stable upon assessment. After assisting the client back to bed, which of the following
should the nurse do?
A. Restrain the client in bed.
B. Complete an incident report.
C. Administer a PRN sedative.
D. Notify the risk manager.
Answer: B. Complete an incident report.
A nurse is assigned to the care of four clients. Which of the following situations
indicates the need for an interdisciplinary conference?
A. A client with end-stage renal disease wants to die at home.
B. A client states that he has just lost his job.
C. A client indicates a desire to go home by taxi.
D. A client relates difficulty getting up from the commode seat.
Answer: A. A client with end-stage renal disease wants to die at home.
Which of the following tasks is appropriate for a nurse to delegate to an assistive
personnel?
A. Instruct a client who is in labor about breathing techniques.
B. Measure oral intake for a client with dehydration.
C. Inspect a preschooler for bruising and skin marks.
D. Evaluate pain relief for a client who has received pain medication.
Answer: B. Measure oral intake for a client with dehydration.
A nurse receives an order to transfer a client in the telemetry unit to the medical unit.
After confirming bed availability on the receiving unit, which of the following is the
nurse's priority action?
A. Call the family to inform them of the transfer.
B. Provide client report to the receiving nurse.
C. Contact the dietary department with transfer information.
D. Inform the billing department of the client's change in status.
Answer: B. Provide client report to the receiving nurse.
Which of the following puts a hospital at the highest risk for infringement of client
record confidentiality?
A. A nurse clusters documentation of care for multiple clients.
B. A provider and nurse access client information using one access code.
C. Paper-based charts are stored at the nurses' station.
D. A nurse performs electronic documentation outside a client's room.
Answer: B. A provider and nurse access client information using one access code.
Two nurses are having a loud verbal discussion at the nurses' station about not wanting
to care for a client with drug-resistant tuberculosis. Which of the following actions
should the charge nurse take?
A. Make arrangements to take over the client's care.
B. Escort the nurses to the nurses' lounge to continue the discussion.
C. Initiate disciplinary action for the nurses who are having the argument.
D. Contact the house supervisor to mediate the conflict.
Answer: B. Escort the nurses to the nurses' lounge to continue the discussion.
According to Health Insurance Portability and Accountability Act (HIPAA) regulations,
which of the following is a violation of client confidentiality?
A. Calling in a prescription to a pharmacy for the spouse to pick up
B. Providing a copy of the record to the transporting paramedic
C. Reporting a client’s disposition to the referring primary care provider
D. Informing housekeeping staff that the client is in the dialysis unit
Answer: D. Informing housekeeping staff that the client is in the dialysis unit
A nurse is reading a chart at the nurses' station, and the unit clerk suddenly snatches the
chart from the nurse. The unit clerk has a history of similar rude behavior when under
stress. Which of the following should the nurse do?
A. Report the unit clerk’s behavior to the nurse manager.
B. Understand that the unit clerk's behavior is due to stress.
C. Assume unit clerk responsibilities to avoid confrontation.
D. Discuss the behavior with the unit clerk at the end of the shift.
Answer: A. Report the unit clerk’s behavior to the nurse manager.
A facility has identified an increase in nosocomial UTIs on the medical-surgical unit. A
nurse is participating in a quality improvement process to address this problem. Which
of the following should be the first step in the process?
A. Develop a tool to track the ongoing incidence of UTIs.
B. Analyze collected data on UTI incidence.
C. Outline a goal of decreasing UTI incidence over the next year.
D. Identify interventions to reduce the incidence of UTIs.
Answer: B. Analyze collected data on UTI incidence.
Which of the following items must be discarded in a biohazard waste receptacle?
A. A urinary catheter drainage bag from a client who is postoperative
B. A bedsheet from a client with bacterial pneumonia
C. A peripaid from a client who is 24-hr post vaginal delivery
D. An empty IV bag removed from a client who has HIV
Answer: A. A urinary catheter drainage bag from a client who is postoperative
Which of the following statements made by a client who is in a clinical research study
indicates proper understanding?
A. “I’m in the study so I get the newest medicine.”
B. “My participation will likely benefit others in the future.”
C. “I will receive better care by being in the study.”
D. “This is the best available treatment for my condition.”
Answer: B. “My participation will likely benefit others in the future.”
A client who is being discharged requires home oxygen. The equipment company has
not yet delivered the oxygen tank. The nurse should
A. send a hospital oxygen tank home with the client.
B. keep the client until the tank arrives.
C. refer the issue to the home health care agency at discharge.
D. give the equipment company's contact information to the client.
Answer: B. keep the client until the tank arrives.
ATI Leadership Proctored Exam Questions and Answers Docx Latest
2020 Test Solution
VERSION 6
A nurse manager is preparing to institute a new system for scheduling staff. Several
nurses have verbalized their concern over the possible changes that will occur. Which of
the following is an appropriate method to facilitate the adoption of the new scheduling
system?
A. Identify nurses who accept the change to help influence other staff nurses
B. Provide a brief overview of the new scheduling system immediately before its
implementation
C. Introduce the new scheduling system by describing how it will save the institution
money
D. Offer to reassign staff who do not support the change to another unit
Answer: A. Identify nurses who accept the change to help influence other staff nurses
A client who is febrile is admitted to the hospital for treatment of pneumonia. In
accordance with the care pathway, antibiotic therapy is prescribed. Which of the
following situations requires the nurse to complete a variance report with regard to the
care pathway?
A. Antibiotic therapy was initiated 2 hr after implementation of the care pathway
B. A blood culture was obtained after antibiotic therapy had been initiated
C. The route of antibiotic therapy on the care pathway was changed from IV to PO
D. An allergy to penicillin required an alternative antibiotic to be prescribed.
Answer: B. A blood culture was obtained after antibiotic therapy had been initiated
A nurse should recognize that an incident report is required when
A. A client refuses to attend physical therapy
B. A visitor pinches his finger in the client’s bed frame
C. A client throws a box of tissues at a nurse
D. A nurse gives a medication 30 minutes late
Answer: B. A visitor pinches his finger in the client’s bed frame
Client satisfaction surveys from a medical-surgical unit indicate that pain is not being
adequately relieved during the first 12 hours post-op. The unit manager decides to
identify post-op pain as a quality indicator. Which of the following data sources will be
helpful in determining the reason why clients are not receiving adequate pain
management after surgery?
A. Prospective chart audit
B. Retrospective chart audit
C. Postoperative care policy
D. Pain assessment policy
Answer: B. Retrospective chart audit
A nurse precepting a newly licensed nurse who is caring for a client who is confused
and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints
to prevent dislodging the IV catheter. Which of the following questions should the
precepting nurse ask?
A. “Did you secure the restraints to the side rails of the bed?”
B. “Are you able to insert two fingers between the restraint and the client’s skin?”
C. “Did you tie the restraints using a double knot?”
D. “Are you removing the client’s restraints every 4 hours?”
Answer: B. “Are you able to insert two fingers between the restraint and the client’s
skin?”
A nurse is caring for an older adult client who has a 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. Arrange the consultation for a time when the nurse caring for the client is able to be
present for the consultation
B. Provide the consultant with subjective opinions and beliefs about the client’s wound
care
C. Request the consultation after several wound care treatments have been tried
D. Arrange for the wound care nurse specialist to see the client daily to provide the
recommended treatment
Answer: A. Arrange the consultation for a time when the nurse caring for the client is
able to be present for the consultation
A client is admitted with TB and placed in a negative pressure room. Which of the
following actions is appropriate?
A. Notify the local health department of the admission
B. Place a sign on the client’s door with the diagnosis
C. Ensure that admitting staff undergo PPD skin tests
D. Determine who had contact with the client in the last 48 hours
Answer: A. Notify the local health department of the admission
A nurse is caring for a client who is unconscious and whose partner is the health care
proxy. The partner has spoken with the provider and wishes to discontinue the client’s
feeding tube. The provider states to the nurse, “I will not discontinue the client’s
treatment. His partner has no right to make decisions regarding the client’s care.” Which
of the following responses by the nurse is appropriate?
A. You should consider speaking with the facility’s ethics committee before making
your decision
B. You have the right to make decisions, even if the partner is the client’s health care
proxy
C. The client has designated his partner as health care proxy in his advance directives
D. We’ll need to have the nursing supervisor review the client’s advance directives
Answer: C. The client has designated his partner as health care proxy in his advance
directives
A nurse is caring for a client who has increased intracranial pressure and is receiving IV
corticosteroids. Which of the following information is most important for the nurse to
report at shift change?
A. Glasgow Coma Scale score
B. Most recent blood glucose reading
C. Lab test scheduled for next shift
D. Reddened area on the coccyx
Answer: A. Glasgow Coma Scale score
A nurse is assigned the following four clients for the current shift. Which of the
following clients should the nurse assess first?
A. A client who has a hip fracture and is in Buck’s traction
B. A client who has aspiration pneumonia and a respiratory rate of 28/min
C. A client who has diabetes mellitus stage 2 pressure ulcer on his foot
D. A client who has a C. diff infection and needs a stool specimen collected
Answer: B. A client who has aspiration pneumonia and a respiratory rate of 28/min
A nurse is caring for a client who fell and is reporting pain in the left hip with external
rotation of the left leg. The nurse has been unable to reach the provider despite several
attempts over the past 30 minutes. Which of the following actions should the nurse
take?
A. Notify the nursing supervisor about the issue
B. Contact the client’s physical therapist
C. Apply a warm compress to the hip
D. Reposition the client for comfort
Answer: A. Notify the nursing supervisor about the issue
The mother of a client with breast cancer states, "It’s been hard for her, especially after
losing her hair. And it has been difficult to pay for all the treatments." Which of the
following actions is appropriate client advocacy?
A. The nurse investigates potential resources to help the client purchase a wig
B. The nurse explains to the mother that most clients with cancer lose their hair
C. The nurse informs the next shift nurse regarding the mother’s concerns
D. The nurse suggests counseling for the client’s body image issues
Answer: A. The nurse investigates potential resources to help the client purchase a wig
Which of the following items must be discarded in a biohazard waste receptacle?
A. A urinary catheter drainage bag from a client who is post-op
B. A bed sheet from a client with bacterial pneumonia
C. A perineal pad from a client who is 24 hours post-vaginal delivery
D. An empty IV bag removed from a client who has HIV
Answer: A. A urinary catheter drainage bag from a client who is post-op
A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t
get better, I’m going to quit.” Which of the following responses is appropriate?
A. “So you are upset about all the changes on the unit”
B. “I think you have a right to be upset, I am tired of the changes too”
C. “Just stick with it a little longer. Things will get better soon”
D. “You should file complaints with the hospital administrator”
Answer: A. “So you are upset about all the changes on the unit”
According to the HIPAA regulations, which of the following is a violation of client
confidentiality?
A. Telephoning the pharmacy with a prescription for the spouse to pick up
B. Providing a copy of the record to the transporting paramedic
C. Reporting a client’s disposition to the referring provider
D. Informing housekeeping staff that the client is in the dialysis unit
Answer: D. Informing housekeeping staff that the client is in the dialysis unit
A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a
sterile procedure. Which of the following actions indicates the nurse is maintaining
sterile technique? (Select all that apply.)
A. Open the sterile pack by first unfolding the flap farthest from her body
B. Rests the cap of a solution container upside down on the sterile field
C. Removes the outside packaging of a sterile instrument before dropping it into the
sterile field
D. Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field
E. Places sterile items within 1.25 cm (0.5 inch) border around the edge of the sterile
field
Answer: A. Open the sterile pack by first unfolding the flap farthest from her body
C. Removes the outside packaging of a sterile instrument before dropping it into the
sterile field
D. Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field
A nurse is providing care for 4 post-op clients. The nurse should first assess the client
A. Whose pulse has been steadily increasing during the past shift
B. Who is reporting a pain level of 8 on a scale of 0 to 10
C. Whose urine output averaged 32 ml/hr for the past 24 hr
D. Who is reporting nausea after the prescribed antiemetic was administered
Answer: A. Whose pulse has been steadily increasing during the past shift
A nurse is preparing to transcribe a client’s med prescription in the medical record.
Which of the following should the nurse recognize as containing the essential
components of a medication order?
A. NPH insulin 10 Units before and at bedtime
B. Haloperidol (Haldol) 1 mg per mouth
C. Multivitamin every morning by mouth
D. Aspirin 650 mg by mouth every 4 hr
Answer: D. Aspirin 650 mg by mouth every 4 hr
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 takes time to plan at the beginning of the 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 takes time to plan at the beginning of the shift
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. Remove the client’s clothing
B. Irrigate the exposed area with water
C. Report the incident to OSHA
D. Don personal protective equipment
Answer: D. Don personal protective equipment
A facility provides annual staff education regarding ethical practice. A charge nurse
recognizes a need for further education when which of the following behaviors is
observed?
A. A nurse refuses to actively participate during an elective abortion procedure
scheduled for her client
B. A nurse gives prescribed opioids to a client who has a terminal illness and
respirations of 8/min
C. A nurse explains to a client’s family that a DNR order includes withholding comfort
measures
D. A nurse informs a confused client who wants to go home that he is going to stay at
the facility until he is better
Answer: C. A nurse explains to a client’s family that a DNR order includes withholding
comfort measures
A nurse in an ambulatory care setting is orienting a newly licensed nurse who is
preparing to return a call to a client. The nurse should explain that which of the
following is an objective of telehealth?
A. Assessing client needs
B. Providing med reconciliation
C. Establishing communication between providers
D. Developing client treatment protocols
Answer: A. Assessing client needs
Which of the following puts a hospital at the highest risk of infringement of client
record confidentiality?
A. A nurse clusters documentation of care for multiple clients
B. A provider and nurse access client info using one access code
C. Paper-based charts are stored at the nurse’s station
D. A nurse performs electronic documentation outside a client’s room
Answer: B. A provider and nurse access client info using one access code
Which of the following observations requires a charge nurse to intervene and
demonstrate safe handling techniques?
A. A nurse cleans up a blood spill with a 1:10 bleach solution
B. A nurse uses goggles to perform tracheostomy suctioning
C. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a
specimen
D. A nurse places a mask on a client with TB before transport to the radiology
department
Answer: C. A nurse disconnects an indwelling urinary catheter from the drainage bag to
collect a specimen
Which of the following should lead a nurse to suspect abuse that must be reported?
A. A school-age child has several bruises on her lower legs
B. A toddler cries whenever his parents enter the hospital room
C. An adolescent admitted to the emergency department won’t speak to his parents
D. A preschool child who was previously toilet trained now requires diapers in the
hospital
Answer: B. A toddler cries whenever his parents enter the hospital room
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. Liaison
B. Pastoral care provider
C. Health educator
D. Personal health counselor
Answer: A. Liaison
A nurse performing triage during a mass casualty incident should recognize that which
of the following clients should be transported to the hospital first?
A. A client who reports substernal chest pain radiating to the neck
B. A client who has an open fracture of the femur
C. A client who has a 4-inch laceration on the forearm
D. A client who has a penetrating head injury and fixed dilated pupils
Answer: A. A client who reports substernal chest pain radiating to the neck
A nurse manager overhears a provider and a staff nurse talking about a client’s diagnosis
in the cafeteria. Which of the following actions should the nurse take first?
A. Provide a staff in-service about client confidentiality
B. Report the incident to the nursing supervisor
C. Remind them that the client info is confidential
D. Fill out an incident report regarding the situation
Answer: C. Remind them that the client info is confidential
A client with a substance use disorder is admitted to the mental health unit and reports
that he has been depressed lately. When preparing for discharge the next day, the client
states: “It’s Ok. Soon everything will be just fine.” Which of the following is the nurse’s
primary first action?
A. Ask the client if he has considered hurting himself
B. Provide the client with info about Alcoholics Anonymous
C. Encourage the client to participate in physical activities
D. Reinforce the need to follow up with the discharge referral
Answer: A. Ask the client if he has considered hurting himself
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. Battery
C. Assault
D. Libel
Answer: B. Battery
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. Report the situation to the director of nursing
B. Have a blood alcohol level drawn from the nurse
C. Document a factual description of the situation
D. Remove the nurse from the unit
Answer: D. Remove the nurse from the unit
A nurse observes a paper bag at the bedside of a client. This finding suggests that the
client is receiving treatment for which of the following respiratory disorders?
A. Asthma
B. Hyperventilation
C. Stridor
D. Atelectasis
Answer: B. Hyperventilation
A nurse is preparing to discharge a client back to a long-term care facility after he was
admitted to an acute care facility 2 days ago for pneumonia. Which of the following
information should the nurse include in the verbal transfer report?
A. Lab results within the expected reference range
B. List of regularly prescribed meds
C. Date of last bowel movement
D. Level of consciousness
Answer: B. List of regularly prescribed meds
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. Review the client’s new lab values
B. Document assessment data
C. Complete required tasks
D. Determine client care goals
Answer: D. Determine client care goals
A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which
of the following statements by the newly licensed nurse indicates understanding of
isolation guidelines?
A. I will instruct visitors to wear a mask when visiting a client who is on contact
precautions
B. I will place a client who has compromised immunity in a negative-pressure airflow
room
C. I will wear an N-95 respirator mask when caring for a client who is on droplet
precautions
D. I will have a client who is on airborne precautions wear a mask when out of her room
Answer: D. I will have a client who is on airborne precautions wear a mask when out of
her room
A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks
is appropriate to delegate to a licensed practical nurse?
A. Changing the dressing on a postoperative wound
B. Referring a client to social services for assistance with transportation
C. Instructing a client who is obese about a low-fat diet
D. Providing the first oral feeding to a client following a stroke
Answer: A. Changing the dressing on a postoperative wound
A case manager working in a rehabilitation unit is discharging to home a client who has
a spinal cord injury level C-7. Which of the following is the priority action when
creating the discharge plan?
A. Select strategies for cost-effective home care
B. Identify the client’s ability to perform activities of daily living
C. Provide educational handouts related to care requirements
D. Recommend community resources available to assist with client care
Answer: B. Identify the client’s ability to perform activities of daily living
A nurse is preparing to complete morning assessments on several assigned clients.
Which of the following clients should the nurse plan to assess first?
A. A client who has a nasogastric tube to intermittent suction and reports nausea
B. A client who has an early morning blood glucose of 220 mg/dl
C. A client who had a bladder scan that indicated 250 ml of urine in the bladder
D. A client who is 3 days post-op & whose dressing has serosanguineous drainage
Answer: A. A client who has a nasogastric tube to intermittent suction and reports
nausea
A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
A. Plan break times for assistive personnel
B. Pick up the meal trays after lunch
C. Administer a nasogastric tube feeding
D. Determine adequacy of ventilator settings
Answer: C. Administer a nasogastric tube feeding
An RN is planning client assignments for a licensed practical nurse (LPN) and three
assistive personnel. The RN should assign the LPN to the client who requires:
A. Recording of daily intake and output
B. Assistance with meals
C. A complete bed bath
D. Frequent dressing changes
Answer: D. Frequent dressing changes
A nurse is caring for 4 clients. Which of the following tasks can be delegated to an
assistive personnel?
A. Assessing a client who just returned from hemodialysis
B. Reviewing dietary instructions for a client with kidney stones
C. Obtaining a stool sample from a client with renal failure
D. Monitoring a client with a fluid restriction
Answer: C. Obtaining a stool sample from a client with renal failure
A charge nurse is making rounds and 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. Remove the restraints from the client’s wrists
C. Speak with the AP about the incident
D. Review the chart for non-restraint alternatives for agitation
Answer: B. Remove the restraints from the client’s wrists
A client is brought to the emergency department (ED) 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. Document the client’s refusal in the chart
B. Tell the client that a catheter will be inserted
C. Obtain a provider’s prescription for a blood alcohol level
D. Assess the client for urinary retention
Answer: A. Document the client’s refusal in the chart
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. Wait to dispose of sharps containers until they are completely full
C. Return unused supplies from the bedside to the unit’s supply stock
D. Store opened bottles of normal saline in a refrigerator for up to 48 hr
Answer: C. Return unused supplies from the bedside to the unit’s supply stock
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. Turning the client
B. Recording the client’s vital signs
C. Determining the client’s pain level
D. Checking the pulses of the client’s right foot
Answer: B. Recording the client’s vital signs
To resolve a conflict between staff members regarding potential changes in policy, a
nurse manager decides to implement the changes she prefers regardless of the feelings
of those who oppose those changes. Which of the following conflict-resolution
strategies is the nurse manager using?
A. Compromising
B. Collaborating
C. Cooperating
D. Competing
Answer: D. Competing
A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the
following clients should be assigned to an RN who has floated from a medical-surgical
unit?
A. A client who has gestational diabetes and is receiving biweekly nonstress tests
B. A primigravida client who is 1 day post-op following a caesarean section and has a
PCA pump
C. A multigravida client who has preeclampsia and is receiving misoprostol (Cytotec)
for induction of labor
D. A client who is at 32 weeks of gestation and has premature rupture of membranes
Answer: B. A primigravida client who is 1 day post-op following a caesarean section
and has a PCA pump
A nurse working on a med-surg unit is managing the care of 4 clients. The nurse should
schedule an interdisciplinary conference for which of the following clients?
A. A client who is at risk for pressure ulcers and has an albumin of 4.2 g/dl
B. A client who has type 1 DM and uses an insulin pump
C. A client who has orthostatic hypotension and is receiving IV fluids
D. A client who is receiving heparin and has an aPTT of 34 seconds
Answer: C. A client who has orthostatic hypotension and is receiving IV fluids
A charge nurse is assessing staff knowledge about safety procedures regarding
needlestick injuries. Which of the following statements by a nurse indicates appropriate
understanding of these safety procedures?
A. Prophylactic treatment should be initiated after a needlestick during preparation of an
injection
B. I should stop the bleeding as soon as possible following a needlestick injury
C. An incident report should be completed if a client receives a stick from her own used
needle
D. The needle should be recapped to prevent injury during transport to the biohazard
container
Answer: C. An incident report should be completed if a client receives a stick from her
own used needle
A nurse on a medical-surgical unit is caring for a group of clients with the assistance of
a licensed practical nurse (LPN) and an assistive personnel. Which of the following
tasks should the nurse assign to the LPN?
A. Obtaining a urine specimen from an older adult client
B. Providing postmortem care for a client who has just died
C. Accompanying a client who just had a wound debridement to physical therapy
D. Reinforcing dietary teaching with a client who has heart disease
Answer: D. Reinforcing dietary teaching with a client who has heart disease
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 info about his mother’s condition
B. Complete an incident report regarding the breach of the client’s confidentiality
C. Log out of the computer so that the client’s son is unable to view his mother’s info
D. Report the possible violation of client confidentiality to the nurse manager
Answer: C. Log out of the computer so that the client’s son is unable to view his
mother’s info
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 oxygen machine has a grounded plug
B. The family keeps a spare oxygen tank in the room
C. The windows of the client’s room are open
D. The client is covered with a woolen blanket
Answer: D. The client is covered with a woolen blanket
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. Elevate the arm for 1 min before taking the blood sample
B. Cap the lancet prior to putting it in the trash
C. Obtain the blood sample from the finger pads
D. Warm the hands prior to piercing the skin
Answer: D. Warm the hands prior to piercing the skin
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. Contact the client’s next of kin to obtain consent for treatment
B. Proceed with treatment without obtaining written consent
C. Have the client sign a consent for treatment
D. Notify risk management before initiating treatment
Answer: B. Proceed with treatment without obtaining written consent
A client has a new permanent pacemaker inserted. Which of the following home care
instructions should the nurse include?
A. The client should avoid using a microwave oven to heat food
B. Regular programming evaluations can be conducted by telephone
C. The client should avoid using remote control devices to prevent dysrhythmias
D. Suctioning could cause the unit to have an electrical shock
Answer: B. Regular programming evaluations can be conducted by telephone
While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that 6 of the 15 records lack documentation regarding advance directives.
Which of the following is the priority action for the nurse to take?
A. Reinforce the potential consequences of not having this info on record to the nursing
staff
B. Ask the nurses who are caring for clients without this info in the medical record to
obtain it
C. Meet with nursing staff to review the policy regarding advance directives
D. Remind nurses to obtain this info during the admission process
Answer: D. Remind nurses to obtain this info during the admission process
A client is admitted with COPD. Which of the following findings should the nurse
report to the provider?
A. Oxygen saturation 89% on room air
B. WBC count 9,000/mm³
C. Report of dyspnea on exertion
D. Bilateral crackles on auscultation of lungs
Answer: D. Bilateral crackles on auscultation of lungs
A charge nurse notices 2 staff nurses are not taking meal breaks during 8-hr shifts.
Which of the following actions should the nurse take first?
A. Provide coverage for the nurse’s breaks.
B. Determine the reasons the nurses are not taking scheduled breaks.
C. Discuss time management strategies with the nurses.
D. Review facility policies for taking scheduled breaks.
Answer: B. Determine the reasons the nurses are not taking scheduled breaks.
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. Occupational therapist
B. Nutritional therapist
C. Physical therapist
D. Mental Health counselor
E. Case manager
Answer: B. Nutritional therapist
D. Mental Health counselor
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. Guardian consent is required for an emancipated minor
B. Consent can be given by a durable power of attorney.
C. A family member can answer any questions the client has about the procedure.
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.
A nurse on a medical-surgical unit is caring for 4 clients. This nurse should recognize
that which of the following clients is the highest priority?
A. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy.
B. A client who has peripheral vascular disease and has absent pedal pulse in right foot.
C. A client who is post-op following a laminectomy 12 hr ago and is unable to void.
D. A client who has methicillin-resistant Staphylococcus Aureus (MRSA) and has an
axillary temp of 38 degree C (101F)
Answer: C. A client who is post-op following a laminectomy 12 hr ago and is unable to
void.
A client scheduled for a tubal ligation procedure starts to cry as she 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. This won’t take long and it will be over before you know it.
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. This won’t take long and it will be over before you know it.
A nurse working in the emergency department is assessing several clients. Which of the
following clients is the highest priority?
A. A client who has a raised red skin rash on his arms, neck, and face
B. A client who reports right-sided flank pain and is diaphoretic
C. A client who reports shortness of breath and left neck and shoulder pain
D. A client who has active bleeding from a puncture wound of the left groin
Answer: D. A client who has active bleeding from a puncture wound of the left groin
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 of the quality improvement process?
A. Review current literature regarding client falls.
B. Implement a fall prevention plan
C. Notify staff of the increased fall rates
D. Identify clients who are at risk for falls
Answer: D. Identify clients who are at risk for falls
A nurse is evaluating a newly licensed nurse who is administering a vitamin K
(Aquamephytoin) injection to a newborn. Which of the following actions by the newly
licensed nurse indicates understanding of the teaching? (Select all that apply.)
A. Selects the dorsogluteal site to administer the injection
B. Cleans the injection site with alcohol
C. Applies gentle pressure at the site after injection
D. Aspirates the syringe for blood return after needle insertion
E. Inserts the needle at a 45 degree angle.
Answer: B. Cleans the injection site with alcohol, C. Applies gentle pressure at the site
after injection
A nurse enters a client’s room and observes a fire in a trash can. Identify, the sequence
of actions the nurse should take. (Move all the actions into the box on the right, placing
them in the 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
E. All of the above
Answer: E
Which of the following actions taken by a nurse constitutes battery?
A. Failing to put up side rails on a confused client’s bed
B. Telling a client who refused his oral medication that he will be given an injection
C. Inserting a feeding tube against the wishes of a client who refuses to eat
D. Threatening to apply wrist restraints to control a client who is agitated
Answer: C. Inserting a feeding tube against the wishes of a client who refuses to eat
