ATI Leadership Proctored Exam Version 8-10 With Answers-459 Solved Questions

ATI Leadership - Proctored (Complete) VERSION 8
1. A client is brought to the emergency department following a motor-vehicle crash. Drug use
is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly
refuses to provide the specimen. Which of the following is the appropriate action by the
nurse?
A. Tell the client that a catheter will be inserted.
B. Document the client’s refusal in the chart.
C. Assess the client for urinary retention.
D. Obtain a provider’s prescription for a blood alcohol level.
Answer: B. Document the client’s refusal in the chart.

2. A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
A. Pick up the meal trays after lunch.
B. Administer a nasogastric tube feeding.
C. Plan break times for assistive personnel.
D. Determine adequacy of ventilator settings.
Answer: B. Administer a nasogastric tube feeding.
3. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a
sterile procedure. Which of the following actions indicates the newly licensed nurse is
maintaining sterile technique? (SATA)
A. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field
B. Opens the sterile pack by first unfolding the top flap away from her body
C. Prepares a container of sterile solution on the field after putting on sterile gloves
D. Removes the outside packaging of a sterile instrument before dropping it onto the sterile
field
E. Holds the sterile solution bottle with the label facing up
Answer: B. Opens the sterile pack by first unfolding the top flap away from her body
C. Prepares a container of sterile solution on the field after putting on sterile gloves

4. A nurse enters a client’s room and identifies that the client is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the
nurse take first?
A. Auscultate the client’s lungs.
B. Notify the provider.
C. Place a faulty equipment tag on the pump.
D. Complete an incident report.
Answer: A. Auscultate the client’s lungs.

5. A nurse is planning care for a group of clients and can delegate care to a licensed practical
nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign
to the LPN?
A. Reinforcing teaching with a client who is learning to self-administer insulin
B. Ambulating a client who is scheduled for discharge later in the day
C. Administering morphine IV bolus to a client who is hr postoperative
D. Admitting a new client who has chronic back pain to the unit
Answer: C. Administering morphine IV bolus to a client who is hr postoperative

6. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After
donning a sterile gown and gloves, which of the following actions by the newly licensed
nurse demonstrates correct aseptic technique?
A. The nurse applies goggles.
B. The nurse turns her back to the sterile field.
C. The nurse holds her hands above her waist.
D. The nurse puts on a face mask.
Answer: D. The nurse puts on a face mask.

7. A nurse who is caring for a group of clients delegates collection of vital signs to an
assistive personnel (AP). Which of the following actions should the nurse take to evaluate the
delegated task?
A. Review vital sign trends at the end of the shift.
B. Recheck vital signs that are outside the expected reference range.
C. Ask the AP to write a summary of the delegated tasks during the shift.

D. Compare the vital signs the AP obtained with those taken by another AP on a previous
shift.
Answer: B. Recheck vital signs that are outside the expected reference range.

8. A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
A. Obtaining a stool sample from a client who has renal failure
B. Monitoring a client who has a fluid restriction
C. Assessing a client who just returned from hemodialysis
D. Reviewing dietary instructions for a client who has kidney stones
Answer: B. Monitoring a client who has a fluid restriction

9. A nurse is triaging a group of clients following a disaster. Which of the following clients
should the nurse recommend for treatment first?
A. A client who has a neck injury and is unable to breathe spontaneously
B. A client who has two open chest wounds with a left tracheal deviation
C. A client who has major burns over 75% of her body surface area
D. A client who has bipolar disorder and is exhibiting signs of hallucination (Class 3)
Answer: A. A client who has a neck injury and is unable to breathe spontaneously

10. A nurse manager is reviewing guidelines for informed consent with the nursing staff.
Which of the following statements by a staff nurse indicates that the teaching was effective?
A. “A family member can interpret to obtain informed consent from a client who is deaf.”
B. “Consent can be given by a durable power of attorney.”
C. “Guardian consent is required for an emancipated minor.”
D. “The nurse can answer any questions the client has about the procedure.”
Answer: A. “A family member can interpret to obtain informed consent from a client who is
deaf.”

11. A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
A. A middle adult client who leaves the facility against medical advice
B. An older adult client who has advanced directives on file
C. A young adult client who is participating in a medical research study

D. An adolescent client whose parents refuse a blood transfusion for religious reasons
Answer: D. An adolescent client whose parents refuse a blood transfusion for religious
reasons

12. A nurse in an ambulatory care setting is orient a newly licensed nurse who is preparing to
return a call to a client. The nurse should explain that which of the following is an objective
of telehealth?
A. Assessing client needs
B. Developing client treatment protocols
C. Providing medication reconciliation
D. Establishing communication between providers
Answer: D. Establishing communication between providers

13. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes.
The client expresses concern about the cost of blood-glucose monitoring supplies. Which of
the following actions should the nurse take?
A. Refer the client to the social services department.
B. Provide the client with a week’s worth of supplies from the hospital.
C. Ask the provider about the possibility of less frequent monitoring.
D. Recommend the client reuse the testing lancets.
Answer: A. Refer the client to the social services department.

14. A charge nurse is receiving change-of-shift report. Which of the following situations
should the charge nurse address first?
A. A nurse on the previous shift wrote an incident report about a medication error.
B. Two staff members have called to say they will be absent.
C. Transport assistance is unavailable to take a client to occupational therapy.
D. The emergency department nurse is waiting to give report on a new admission.
Answer: C. Transport assistance is unavailable to take a client to occupational therapy.

15. A nurse who is precepting a newly licensed nurse is discussing the client assignment for
the shift. Which of the following actions should the nurse preceptor take first to demonstrate
appropriate time management?
A. Complete required tasks.

B. Review the client’s new laboratory values.
C. Determine client care goals.
D. Document assessment data.
Answer: C. Determine client care goals.

16. A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which
of the following statements by a staff nurse indicates understanding?
A. “Clients who participate in research studies forfeit their HIPAA right to privacy.”
B. “HIPAA allows facility-specific coding of client health care information to ensure
privacy.”
C. “HIPAA prohibits the uploading of photographs of client’s providers to social media sites.”
D. “HIPAA allows clients to request a review of their own medical records.”
Answer: D. “HIPAA allows clients to request a review of their own medical records.”

17. A nurse is caring for a client who has a tumor. The provider recommends surgery. The
client refuses, but the client’s partner wants the surgery performed. Which of the following is
the deciding factor in determining if the surgery will be done?
A. Whether the client understands the risk of refusing the procedure
B. Whether the facility ethics committee reached a consensus on the case
C. Whether the partner is the client’s durable power of attorney for health care
D. Whether the client’s refusal is based on religious belief
Answer: C. Whether the partner is the client’s durable power of attorney for health care

18. A charge nurse is planning the care of four newborns. An assistive personnel and licensed
practical nurse are available for staffing. Which of the following tasks should the nurse assign
to a licensed practical nurse?
A. Conduct the newborn hearing screening.
B. Administer a hepatitis B vaccine.
C. Perform a New Ballard screening.
D. Obtain vital signs.
Answer: B. Administer a hepatitis B vaccine.

19. During a staff meeting a unit manager reviews the results for documenting client
education and finds that they are below the benchmark. Which of the following strategies
should the nurse manager implement first?
A. Train LPNs to reinforce teaching with clients using a standardized teaching plan.
B. Determine factors that interfere with the documentation of client education.
C. Include documentation of client education as part of unit nurses’ annual performance
evaluation.
D. Offer incentives for the staff once the unit’s results are back in adherence with the
benchmark.
Answer: B. Determine factors that interfere with the documentation of client education.

20. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should
explain that preventing client injury by removing a fall hazard demonstrates which of the
following ethical principles?
A. Utility
B. Autonomy
C. Nonmaleficence
D. Veracity
Answer: C. Nonmaleficence

21. A nurse is caring for a group of clients. Which of the following clients should the nurse
plan to assess first?
A. A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past 24 hr
B. A client who has diabetes mellitus and reports paresthesia in his fingers and toes
C. A client who has a nasogastric tube and has crackles in the lungs
D. A client who has a new diagnosis of Graves’ disease and a TSH level of 0.2 microunits/mL
Answer: C. A client who has a nasogastric tube and has crackles in the lungs

22. A charge nurse is planning to evacuate clients on the unit because there is a fire on
another floor.
Which of the following clients should the nurse evacuate first?
A. A client who is in Buck’s traction for a left hip fracture
B. A client who is 1 day postoperative following thoracic surgery and has a chest tube
C. A client who is confused and restrained for safety

D. A client who is receiving IV chemotherapy and is ambulatory
Answer: B. A client who is 1 day postoperative following thoracic surgery and has a chest
tube
23. A nurse enters the room of a client who is unconscious and finds that the client’s son is
reading her electronic medical records from a monitor located at the bedside. Which of the
following actions should the nurse take first?
A. Recommend the son meet with the provider to get information about his mother’s
condition.
B. Report the possible violation of client confidentiality to the nurse manager.
C. Complete an incident report regarding the breach of the client’s confidentiality.
D. Log out the computer so that the client’s son is unable to view his mother’s information.
Answer: B. Report the possible violation of client confidentiality to the nurse manager.

24. A nurse is preparing a client for cardiac catheterization. Just before the procedure, the
client asks the nurse about the risks of the procedure. Which of the following actions should
the nurse take?
A. Explain the risks of the procedure to the client.
B. Convey the client’s request to the nurse who witnessed the consent.
C. Check to see if the medical record indicates the provider explained the procedure to the
client.
D. Notify the provider about the client’s concerns.
Answer: C. Check to see if the medical record indicates the provider explained the procedure
to the client.

25. A nurse is prioritizing care after receiving change-of-shift report on four clients. Which of
the following clients should the nurse assess first?
A. A client who reports a headache with sensitivity to light
B. A client who reports an urge to void but has not urinated during the prior shift
C. A client who reports indigestion and pain in her jaw
D. A client who reports feeling lightheaded when he stands up from a lying position
Answer: D. A client who reports feeling lightheaded when he stands up from a lying position

26. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts.
Which of the following actions should the nurse take first?
A. Discuss time management strategies with the nurses.
B. Determine the reasons the nurses are not taking scheduled breaks.
C. Provide coverage for the nurses’ breaks.
D. Review facility policies for taking scheduled breaks.
Answer: B. Determine the reasons the nurses are not taking scheduled breaks.

27. A nurse is preparing to delegate bathing and turning of a newly admitted client who has
end-stage bone cancer to an experienced assistive personnel (AP). Which of the following
assessments should the nurse make before delegating care?
A. Has the AP checked the client’s pain level prior to turning her?
B. Is the client’s family present so the AP can show them how to turn the client?
C. Has data been collected about specific client needs related to turning?
D. Does the AP have the time to change the client’s central IV line dressing after turning her?
Answer: C. Has data been collected about specific client needs related to turning?

28. A nurse is preparing to transfer a client from the emergency department to a medicalsurgical unit using the SBAR communication tool. Which of the following information
should the nurse include in the background portion of the report?
A. A prescribed consultation
B. The client’s vital signs
C. The client’s name
D. The client’s code status
Answer: A. A prescribed consultation

29. A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the
following statements by the client should the nurse identify as an indication that a referral to
an occupation therapist is necessary?
A. “I need some help planning my meals to maintain my weight.”
B. “I am tired of having pain in my joints all the time.”
C. “I’m having difficulty climbing the stairs at my house.”
D. “I will need assistance with bathing.”
Answer: C. “I’m having difficulty climbing the stairs at my house.”

30. A nurse in the emergency department is caring for a 16-year-old client who reports
abdominal pain and is accompanied by an adult neighbor. The provider diagnoses a ruptured
appendix and states that the client requires an emergency appendectomy. Which of the
following actions should the nurse?
A. Ask the adult neighbor to sign the consent form.
B. Obtain consent from the hospital administrator.
C. Witness the client signing the consent form.
D. Attempt to notify the client’s guardian to obtain consent.
Answer: D. Attempt to notify the client’s guardian to obtain consent.

31. A nurse on a medical-surgical unit is caring for four clients. Which of the following
findings is the highest priority?
A. A client who had a cardiac catheterization whose capillary refill in the great toe is 4
seconds
B. A client who has COPD and has an oxygen saturation of 90%
C. A client who had a cholecystectomy 6 hr ago and is requesting pain medication
D. A client whose TPN was discontinued 4 hr ago and is requesting clear liquids
Answer: C. A client who had a cholecystectomy 6 hr ago and is requesting pain medication

32. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following
actions should the charge nurse take?
A. Assign clients who are not prescribed narcotics to the staff nurse.
B. Collect data about the staff nurse to support further action.
C. Report the staff nurse to the facility ethics committee.
D. Counsel the staff nurse about substance use.
Answer: B. Collect data about the staff nurse to support further action.
33. A nurse is assessing a client’s comprehension of a pulmonary function test prior to the
procedure. Which of the following client statements indicates to the nurse an understanding
of the procedure?
A. “I will be given contrast dye during this test.”
B. “I might have to wear a nose clip during this test.”
C. “I might have a tube inserted into my airway during the test.”

D. “I will run on a treadmill during this test.”
Answer: B. “I might have to wear a nose clip during this test.”

34. A nurse in the emergency department is triaging four clients. Which of the following
clients should the nurse recommend to be examined first?
A. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood
B. An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from
0 to 10
C. An older adult client who has dyspnea and a respiratory rate of 26/min
D. An adult client who has large ecchymosis on both legs
Answer: C. An older adult client who has dyspnea and a respiratory rate of 26/min
35. A home health nurse finds piles of newspapers in the hallway of a client’s home. The
nurse explains the need to discard the newspapers for safety reasons. The client agrees to
move the newspapers into the living room. Which of the following conflict resolution
strategies has the nurse used?
A. Collaborating
B. Smoothing
C. Accommodating
D. Compromising
Answer: C. Accommodating

36. A nurse is planning to delegate client care assignments. Which of the following tasks
should the nurse plan to delegate to an assistive personnel?
A. Advising a client on self-administration of acetaminophen
B. Informing a family of a client’s progress in physical therapy
C. Teaching a client to perform a finger-stick for testing blood glucose levels
D. Performing post-mortem care prior to transferring the client to the morgue
Answer: D. Performing post-mortem care prior to transferring the client to the morgue

37. A nurse is providing discharge teaching to a client following a total knee arthroplasty.
Which of the following information should the nurse include (SATA)
A. Advance directives information
B. Contact information for the physical therapist

C. Medication guidelines information
D. Insurance information
E. Information about follow-up care
Answer: b, c, e

38. A nurse is planning to discharge a client who has terminal cancer and suggests that the
family might benefit from respite services. When the client’s partner asks how this service
can help, which of the following responses by the nurse is appropriate?
A. “This service offers psychological interventions during and after your wife’s illness.”
B. “The clinicians help reduce the severity of your wife’s physical problems.”
C. “This service delivers meals and supplies to reduce your errands away from home.”
D. “It makes it possible for you to have some time away from caring for your wife.”
Answer: D. “It makes it possible for you to have some time away from caring for your wife.”

39. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the
following instructions should the nurse include?
A. Warm the hands prior to piercing the skin.
B. Cap the lancet prior to putting it in the trash.
C. Elevate the arm for 1 min before taking the blood sample.
D. Obtain the blood sample from the finger pads.
Answer: A. Warm the hands prior to piercing the skin.

40. A nurse is assessing a client who had a recent stroke. Which of the following findings
should indicate the need for referral to an occupational therapist?
A. Receptive aphasia
B. Facial drooping
C. Memory loss
D. Unilateral neglect
Answer: D. Unilateral neglect

41. A nurse is participating in the development of a disaster management plan for a hospital.
The nurse should recognize that which of the following resources is the highest priority to
have available in response to a bioterrorism event?
A. A network for communication between staff members and families

B. A mental health specialist on the response team
C. A sufficient supply of personal protective equipment
D. A system for tracking client information
Answer: C. A sufficient supply of personal protective equipment

42. A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the
following diseases should the nurse report to the state health department?
A. Rotavirus
B. Pertussis
C. Respiratory syncytial virus
D. Group B streptococcal disease
Answer: B. Pertussis

43. A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment
used for a client who has Clostridium difficile. Which of the following solutions should the
nurse recommend to clean the equipment?
A. Chlorine bleach
B. Triclosan
C. Chlorhexidine
D. Isopropyl alcohol
Answer: A. Chlorine bleach

44. A nurse is assessing an older adult client who was brought to the emergency department
by his adult son, who reports that the client fell at home. The nurse suspects elder abuse.
Which of the following actions should the nurse take?
A. Treat and discharge the client.
B. Ask the client’s son to go to the waiting area.
C. File an incident report.
D. Ask the client about his injuries with the son present
Answer: D. Ask the client about his injuries with the son present

45. A nurse is completing discharge teaching with a client who is being treated for
tuberculosis (TB). Which of the following statements by the client indicates an understanding
of the teaching?

A. “I need to take my prescribed medication for 3 months.”
B. “I should have a sputum culture done every 2 to 4 weeks.”
C. “I need to have a TB skin test done once per year.”
D. “I should wear a mask while around my family.”
Answer: D. “I should wear a mask while around my family.”

46. An older adult client is awaiting surgery for a fractured right hip. The nurse should
recognize that which of the following can be delegated to an assistive personnel?
A. Checking the pulses of the client’s right foot
B. Recording the client’s vital signs
C. Turning the client
D. Determining the client’s pain level
Answer: C. Turning the client

47. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP).
Which of the following is an appropriate task for the AP?
A. Inspect the skin of a newborn who is receiving phototherapy.
B. Answer the parents’ questions about newborn circumcision.
C. Show a new mother how to change the newborn’s diaper.
D. Obtain the weight of a newborn that is receiving formula
Answer: D. Obtain the weight of a newborn that is receiving formula

48. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “A provider can write a prescription for restraints ‘as needed’.”
B. “I need to tie the restraint to the part of the bed frame that moves.”
C. “I should tie the restraints using a square knot.”
D. “I will remove a client’s restraints every 4 hours.”
Answer: A. “A provider can write a prescription for restraints ‘as needed’.”

49. An infection control nurse is planning an education program for a group of newly licensed
nurses. Which of the following infections should the nurse include when discussing illnesses
requiring droplet precautions?
A. Mumps

B. Rubeola
C. Varicella
D. Rotavirus
Answer: A. Mumps

50. A nurse is caring for a client who has cancer. The client and her partner are asking the
nurse about hospice are. Which of the following statements by the nurse is appropriate?
A. “Hospice care will prolong the life expectancy of clients who are terminally ill.”
B. “Hospice care is a multidisciplinary program for clients who are terminally ill.”
C. “Hospice care is helpful for clients at various stages of chronic illness.”
D. “Hospital access is no longer available for clients who are in hospice care.”
Answer: B. “Hospice care is a multidisciplinary program for clients who are terminally ill.”
51. A nurse is planning care for a client who has Addison’s disease. Which of the following
tasks should the nurse plan to delegate to an assistive personnel?
A. Decide how often to measure vital signs.
B. Explain to the client about a 24-hr urine specimen collection.
C. Determine the client’s muscle strength prior to ambulation.
D. Remind the client to change positions slowly.
Answer: D. Remind the client to change positions slowly.

52. A charge nurse discovers that a staff nurse on the unit has made repeated medication
errors. Which of the following actions should the charge nurse take first?
A. Notify the risk management department of the situation.
B. Review with the nurse the principles of medication administration.
C. Ask the nurse to describe her medication administration procedure.
D. Identify education opportunities for the nurse regarding safe medication administration.
Answer: C. Ask the nurse to describe her medication administration procedure.

53. A case manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse
manager should identify that which of the following torts has occurred?
A. Libel
B. Battery

C. Slander
D. Negligence
Answer: C. Slander

54. A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold
wedding band. Which of the following is an appropriate procedure for taking care of this
client’s ring?
A. Place the client’s ring in the facility safe.
B. Tape the ring securely to the client’s finger.
C. Place the ring in the bag with the client’s clothing.
D. Agree to keep the ring for the client until after surgery.
Answer: C. Place the ring in the bag with the client’s clothing.

55. A nurse is prioritizing postpartum care for four clients. Which of the following actions
should the nurse take first?
A. Assist a client who requests help breastfeeding her 4-hr-old newborn.
B. Administer RH immune globulin to a client who is Rh-negative and 6 hr postpartum.
C. Check uterine tone for a client who received methylergonovine.
D. Instruct a client who has an episiotomy about a sitz bath.
Answer: B. Administer RH immune globulin to a client who is Rh-negative and 6 hr
postpartum.

A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After
the nurse administers the prescribed opioid and benzodiazepine, the client
A. Withhold the benzodiazepine but continue the opioid.
B. Contact the provider about replacing the opioid with an NSAID.
C. Administer the benzodiazepine but withhold the opioid.
D. Continue the medication dosages that relieve the client’s pain.
Answer: A. Withhold the benzodiazepine but continue the opioid.

57. A nurse is observing an assistive personnel (AP) administer 0.9% sodium chloride enema
to an adult client. For which of the following actions by the AP should the nurse intervene?
A. Administers the solution at room temperature.
B. Points tubing in the direction of the umbilicus during insertion.

C. Positions the client on her left side with knees flexed.
D. Inserts the tubing 8 cm (3.1 in) into the rectum.
Answer: B. Points tubing in the direction of the umbilicus during insertion.

58. A nurse is providing information to a client about advance directives. The nurse should
explain that advance directives include which of the following?
A. Instructions regarding treatments the client desires or does not desire.
B. Information regarding the disposition of the client’s body upon death.
C. Information regarding organ donation.
D. A form with directions for contacting next of kin.
Answer: A. Instructions regarding treatments the client desires or does not desire.

59. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize
that which of the following clients is the highest priority?
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right
foot.
B. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy.
C. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38°C (101°F).
D. A client who is postoperative following a laminectomy 12 hr ago and is unable to void.
Answer: C. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an
axillary temperature of 38°C (101°F).

60. A staff development nurse is giving an in-service presentation about advocacy in nursing.
Which of the following statements by a nurse indicates an understanding of the role of a
client advocate?
A. “In the role of client advocate, I should take responsibility for coordinating each client’s
care.”
B. “As a client advocate, I will suggest the best course of action for clients who are
indecisive.”
C. “My role as a client advocate is to empower the clients to make informed healthcare
decisions.”
D. “As a client advocate, I will adhere to the provider’s prescribed treatments.”

Answer: C. “My role as a client advocate is to empower the clients to make informed
healthcare decisions.”

61. A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to
the bedside commode. Which of the following actions should the nurse take first?
A. Refer the AP to the facility procedure manual.
B. Instruct the AP to request assistance when unsure about a task.
C. Help the AP assist the client with the transfer.
D. Demonstrate the proper client transfer technique for the AP.
Answer: D. Demonstrate the proper client transfer technique for the AP.

62. A nurse at the local health department is caring for four clients who have communicable
diseases. Which of the following infections should the nurse report to the state health
department?
A. Chlamydia trachomatis
B. Pediculosis capitis
C. Impetigo contagiosa
D. Candida albicans
Answer: A. Chlamydia trachomatis to the state health department.
63. A charge nurse witnesses two nurses having a loud discussion at the nurses’ station about
not wanting to care for a client who has drug-resistant tuberculosis. Which of the following
actions should the charge nurse take?
A. Escort the nurses to the nurses’ lounge to continue the discussion.
B. Recommend that both nurses be terminated.
C. Make arrangements to take over the client’s care.
D. Contact the house supervisor to mediate the conflict.
Answer: D. Contact the house supervisor to mediate the conflict.

64. A newly licensed nurse is floating to an unfamiliar unit and determines that he does not
have sufficient experiences to safely care for his assigned clients. Which of the following
actions should the nurse take?
A. Accept the assignment with help from assistive personnel on the unit.
B. Request that the charge nurse modify the assignment.

C. Document the concern in the nurse’s notes.
D. Notify the risk manager.
Answer: B. Request that the charge nurse modify the assignment.

65. A nurse is conducting an in-service about the nursing code of ethics with a group of newly
licensed nurses. Which of the following information should the nurse include in the teaching
as an example of advocacy?
A. Recommending a referral for a client who requires physical therapy
B. Suggesting a client’s partner attend a support group for emotional support
C. Evaluating a client’s home for safety hazards
D. Completing an incident report following a medication error
Answer: A. Recommending a referral for a client who requires physical therapy as an
example of advocacy.

66. A charge nurse in the emergency department is supervising a nurse who is floating from
the medical-surgical unit. Which of the following assignments is appropriate for the float
nurse?
A. Administer IV nitroglycerin to a client who is experiencing chest pain.
B. Perform a urinary catheterization for a client who has experienced a cerebrovascular
accident.
C. Set up a trauma room for an incoming client who was in a motor-vehicle crash.
D. Complete a SAD PERSONS assessment scale for a client who has attempted suicide.
Answer: C. Set up a trauma room for an incoming client who was in a motor-vehicle crash.

67. A home health nurse is assessing the home environment during an initial visit to a client
who has history of falls. Which of the following findings should the nurse identify as
increasing the client’s risk for falls? (SATA)
A. A folding chair without arm rests
B. A wheeled office chair at the client’s computer desk
C. A throw rug covering some cracked vinyl flooring in the kitchen
D. A two-wheeled walker used to assist the client with ambulation
E. A raised vinyl seat on the toilet in the bathroom
Answer: B. A wheeled office chair at the client’s computer desk and
C. A throw rug covering some cracked vinyl flooring in the kitchen.

68. A nurse in a long-term care facility should identify that which of the following will
provide security for clients who have dementia?
A. Turning off room lights at night
B. Using a facility
C. Restricting space to reduce pacing
D. Setting alarms on exits
Answer: D. Setting alarms on exits will provide security for clients who have dementia.

69. A nurse in the emergency department is preparing to care for a client who arrived via
ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following
actions should the nurse take?
A. Have the client sign a consent for treatment
B. Notify risk management before initiating treatment
C. Proceed with treatment without obtaining written consent (Implied Consent)
D. Contact the client’s next of kin to obtain consent for treatment
Answer: C. Proceed with treatment without obtaining written consent (Implied Consent).

70. A nurse is reviewing the medication administration record of a client and notices that an
additional dose of medication has been administered. Which of the following actions should
the nurse take first?
A. Inform the nursing supervisor.
B. Notify the provider
C. Observe the client’s condition.
D. Complete an incident report.
Answer: C. Observe the client’s condition.

1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change
in the wound care procedure. Which of the following findings indicate wound healing?
A. Erythema on the skin surrounding a client's wound
B. Deep red color on the center of the client's wound
C. Inflammation noted on the tissue edges of a client's wound
D. Increase in serosanguineous exudate from the client's wound
Answer: B. Deep red color on the center of the client's wound.

2. A nurse received change of shift report at 0700 for four clients. Which of the following
actions should the nurse perform first?
A. Obtain a breakfast tray for a client who received a morning dose of insulin aspart
B. Administer pain medication to a client who has rheumatoid arthritis and received the last
dose at 0400
C. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
D. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours.
Answer: C. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900.

3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the
following clients should the nurse assign to the newly licensed nurse?
A. A client who has multiple sclerosis and ataxia
B. A client who has a brain tumor and is admitted for chemotherapy
C. A client who has Guillain-Barre syndrome and a tracheostomy
D. A client who sustained a concussion and is being monitored for complications
Answer: D. A client who sustained a concussion and is being monitored for complications to
the newly licensed nurse.

4. A nurse is providing teaching to a client about advance directives. Which of the following
statements by the client indicates an understanding of the teaching?
A. “Once I sign my living will, a family member must co-sign it.”
B. “I will wait until I have a serious health problem to sign my advance directives.”
C. “My doctor will need to provide approval for the decisions outlined in my living will.”
D. “My durable power of attorney for health care is part of my advance directives.”
Answer: D. “My durable power of attorney for health care is part of my advance directives.”

5. A nurse is chairing a committee about preventing infant abduction in a new birth care
center. Which of the following quality control tasks should the nurse assign to be completed
first?
A. Identify the industry standards for infant safety
B. Evaluate the selected infant safety system
C. Choose an infant safety system
D. Establish measurement criteria for infant safety systems

Answer: A. Identify the industry standards for infant safety.

6. A nurse notes that a client is eating about half of the food on his plate and coughs
frequently during meals. The nurse plans to perform dysphagia screening to determine the
client's need for a referral to which of the following providers?
A. Physical therapist
B. Respiratory therapist
C. Speech therapist
D. Occupational therapist
Answer: C. Speech therapist for dysphagia screening.

7. A home health nurse is assessing the home environment during an initial visit to a client
who has a history of falls. Which of the following findings should the nurse identify as
increasing the client's risk for falls? (Select all that apply)
A. A wheeled office chair at the client's computer desk
B. A raised vinyl seat on the toilet in the bathroom
C. A throw rug covering some cracked floor
D. A folding chair without arm rests
E. A two-wheeled walker used to assist the client with ambulation
Answer: B. A raised vinyl seat on the toilet in the bathroom
C. A throw rug covering some cracked floor
E. A two-wheeled walker used to assist the client with ambulation

8. A nurse manager is planning to assign care for four clients on a medical-surgical unit.
Which of the following clients should the nurse assign to a LPN?
A. An older adult who has lung cancer and has periodic episodes of severe dyspnea
B. A middle adult client who has a below the knee amputation and requires a dressing change
C. A young adult client who is postoperative, receiving morphine via epidural, and reports
pruritus
D. An adolescent who requires teaching regarding insulin administration
Answer: B. A middle adult client who has a below the knee amputation and requires a
dressing change.

9. While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that six of the 15 records lack documentation regarding advance directives.
Which of the following is the priority for the nurse to take?
A. Remind nurses to obtain this information during the admission process
B. Reinforce the potential consequences of not having this information on record to the
nursing staff
C. Meet with nursing staff to review the policy regarding advance directives
D. Ask nurses who are caring for clients without this information in the medical record to
obtain it
Answer: C. Meet with nursing staff to review the policy regarding advance directives.

10. A nurse is caring for a group of clients. Which of the following should the nurse see first?
A. A client who is postoperative and has a fever.
B. A client whose pressure ulcer has serosanguineous drainage on the dressing.
C. A client who has diabetes mellitus and is diaphoretic.
D. A client who has a fractured hip and reports a pain level of 7 on a scale from 0-10.
Answer: A. A client who is postoperative and has a fever.

11. A nurse is receiving change-of-shift report for four clients. Which of the following clients
should the nurse care for first?
A. A client who is 4 hr postoperative following a hernia repair and has pitting edema of the
right leg
B. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea
C. A client who has pneumonia and requires a tracheostomy dressing change
D. A client who has a new colostomy and requires discharge teaching
Answer: A. A client who is 4 hr postoperative following a hernia repair and has pitting
edema of the right leg

12. A nurse manager discovers there is a conflict between nurses working the day shift and
nurses working on the night shift. Which of the following actions should the nurse manager
take first?
A. Acknowledge the conflict and encourage the nurses to focus on working as a team
B. Gather information regarding the situation
C. Encourage the nurses to resolve the conflict autonomously

D. Meet with a committee from each shift to discuss issues related to the conflict
Answer: B. Gather information regarding the situation

13. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid
chemical in an industrial setting. Which of the following actions should the nurse take first?
A. Don personal protective equipment
B. Irrigate the exposed area with water
C. Remove the client’s clothing
D. Report the incident to OSHA
Answer: A. Don personal protective equipment

14. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong
client. Which of the following actions should the nurse perform first?
A. Complete an incident report
B. Measure the client’s vital signs
C. Inform the nurse manager
D. Call the provider
Answer: B. Measure the client’s vital signs

15. A nurse is assessing a client who has meningitis. Which of the following findings should
the nurse report to the provider immediately?
A. Decreased level of consciousness
B. Generalized rash over trunk
C. Increased temperature
D. Report of photophobia
Answer: A. Decreased level of consciousness

16. A client who is febrile is admitted to the hospital for treatment of pneumonia. In
accordance with the care pathway, antibiotic therapy is prescribed. Which of the following
situations requires the nurse to complete a variance report with regard to the care pathway?
A. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.
B. A blood culture was obtained after antibiotic therapy had been initiated
C. An allergy to penicillin required an alternative antibiotic to be prescribed
D. The route of antibiotic therapy on the care pathway was changed from IV to PO

Answer: B. A blood culture was obtained after antibiotic therapy had been initiated

17. A nurse manager is making staffing assignments for the maternal newborn unit. Which of
the following clients should the nurse manager assign to a float nurse from the medicalsurgical unit?
A. A client who is post term and is receiving oxytocin for labor induction
B. A client who gave birth to her first child and requires instruction on breastfeeding
techniques
C. A client who is 2 days post-operative following a caesarean birth and is having difficulty
ambulating
D. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion
Answer: C. A client who is 2 days post-operative following a caesarean birth and is having
difficulty ambulating

18. A nurse is coordinating an interprofessional team to review proposed standards to reduce
the transmission of methicillin-resistant Staphylococcus aureus (MRSA). Which of the
following members of the interprofessional team should the nurse consult?
A. Risk management coordinator
B. Clinical pharmacist
C. Nursing supervisor
D. Infection control nurse
Answer: D. Infection control nurse

19. A nurse is caring for a client who has uterine prolapse. The provider has recommended a
total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option.
Which of the following is an appropriate action for the nurse to take?
A. Discuss with the client her concerns regarding the procedure
B. Provide the client with information on treatment options and outcomes
C. Inform the client of the consequences of uterine prolapse and the need for intervention
D. Initiate a mental health consult to determine the client’s reasons for refusing surgery
Answer: A. Discuss with the client her concerns regarding the procedure

20. A nurse in the emergency department is assessing a client who is unconscious following a
motor-vehicle crash. The client requires immediate surgery. Which of the following actions
should the nurse take?
A. Delay the surgery until the nurse can obtain informed consent
B. Obtain telephone consent from the facility administrator before the surgery.
C. Ask the anesthesiologist to sign the consent.
D. Transport the client to the operating room without verifying informed consent.
Answer: D. Transport the client to the operating room without verifying informed consent.

21. A nurse is planning to delegate client care assignment. Which of the following tasks
should the nurse plan to delegate to an assistive personnel?
A. Performing postmortem care prior to transferring the client to the morgue
B. Advising a client on self-administration of acetaminophen
C. Teaching a client to perform a finger-stick for testing blood glucose levels
D. Informing a family of a client’s progress in physical therapy
Answer: A. Performing postmortem care prior to transferring the client to the morgue

22. A nurse is working on a quality improvement team that is assessing an increase in client
fall at the facility. After problem identification, which of the following actions should the
nurse plan to take first as part of the quality improvement process?
A. Notify staff of the increased fall rate
B. Review current literature regarding client falls
C. Implement a fall prevention plan
D. Identify clients who are at risk of falls
Answer: D. Identify clients who are at risk of falls

23. A nurse is completing performance evaluation for an assistive personnel (AP). Which of
the following actions by the AP requires intervention by the nurse?
A. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile.
B. The AP closes the door of a client who is on airborne precautions.
C. The AP Removes cut flowers from the room of a client who is in protective environment.
D. The AP wears a mask when a caring for a client who has varicella.
Answer: A. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium
difficile.

24. A charge nurse notices that the staff nurse are having difficulty using new IV infusion
pumps for medication administration. Which of the following is priority action by the charge
nurse?
A. Assess the staff nurse’s knowledge deficit.
B. Pair an inexperienced nurse with an experienced nurse.
C. Demonstrate use of the pump during medication administration.
D. Plan an in-service education program on the unit.
Answer: A. Assess the staff nurse’s knowledge deficit.

25. A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which
of the following tasks should the nurse assign to the AP?
A. Administer the initial bolus feeding to a client who has NG tube
B. Check a client pain level 30min after receiving acetaminophen
C. Collect urine specimen for newly admitted client
D. Instruct a client to splint an abdominal incisions
Answer: C. Collect urine specimen for newly admitted client

26. A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag
to a client. Which of the following actions should the nurse take?
A. Treat the client’s injuries within 30 min
B. Provide treatment for life-threatening injuries
C. Provide treatment for minor injuries
D. Allow the client to die without further intervention
Answer: B. Provide treatment for life-threatening injuries
27. A home health nurse is performing a safety assessment of a client’s home. Which of the
following findings should the nurse identify as a safety hazard?
A. The client has used tracks to secure the carpet on the stairs
B. The client’s electrical cord is taped to the floor
C. The client’s bedside lamp is plugged in using an extension cord with two prongs
D. The client stores cleaning supplies in a locked cabinet above his head
Answer: C. The client’s bedside lamp is plugged in using an extension cord with two prongs

28. A charge nurse is observing a newly licensed nurse provide care for a client who has
Clostridium difficile infections. Which of the following actions by the newly licensed nurse
indicate an understanding of proper infection control procedures?
A. Applies a mask before entering the client’s room (It’s contact precaution)
B. Removes fresh flowers from the client’s room.
C. Washes her hands with an alcohol-based hand rub after caring for the client.(no,
ineffective and must wash hands with soap/water)
D. Wears gown when caring for client
Answer: D. Wears gown when caring for client

29. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following supplies to manage
tracheostomy at home? (SATA)
A. Pipe cleaners
B. O2 Tank
C. Cotton balls
D. Petroleum Jelly
E. Obturator
Answer: A. Pipe cleaners
B. O2 Tank
E. Obturator

30. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the
following clients can give informed consent?
A. An adult client who has alcohol intoxication-NOT FOCUSED
B. An adolescent client who is legally emancipated
C. An older adult client who has questions about the procedure = having questions means you
don’t understand,
D. An adult client who has moderate Alzheimer’s disease.- cant consent if you are not
Answer: B. An adolescent client who is legally emancipated

31. A nurse is discussing the safekeeping of valuables with a client who is scheduled for
surgery. Which of the following client statements indicates the need for further teaching?
A. “I can wear my ankle bracelet since i am just having a local anaesthetic:

B. “I can leave my wedding ring on if it is taped in place”
C. “I should remove my dentures before the procedure”
D. “I should leave my valuables with a family member”
Answer: B. “I can leave my wedding ring on if it is taped in place”

32. A nurse is caring for an older adult client who has Stage III pressure ulcer. The nurse
requests a consultation with the wound care specialist. Which of the following actions by the
nurse is appropriate when working with a consultant?
A. Request the consultation after several wound care treatments are tried
B. Arrange for the wound care nurse specialist to see the client daily to provide the
recommended treatments
C. Arrange the consultation for a time when the nurse caring for the client is able to be
present for the consultation
D. Provide the consultant with subjective opinions and beliefs about the client’s wound care
Answer: C. Arrange the consultation for a time when the nurse caring for the client is able to
be present for the consultation

33. A nurse is observing an AP administer 0.9% sodium chloride enema to an adult client. For
which of the following actions by the AP should the nurse intervene?
A. Positions the client on her left side with knees flexed
B. Administers the solution at room temp
C. Points tubing in the direction of the umbilicus during insertion
D. Inserts the tubing 8cm (3.1 in) into the rectum
Answer: A. Positions the client on her left side with knees flexed

34. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “I should encrypt personal health information when sending emails.”
B. “I can post the client’s vital signs in the client’s room.”
C. “I can use another nurse’s password as long as I log off after using the computer”
D. “I should discard personal health information documents in the trash before leaving the
unit”
Answer: A. “I should encrypt personal health information when sending emails.”

35. A nurse is participating on a committee that is considering the creation of a policy that
will allow the nurses to remove chest tubes. Which of the following is an appropriate
resource for the nurse to consult in planning for this policy? (2016 practice)
A. ANA Standards of Practice
B. ANA Code of Ethics
C. State Nurse Practice Act
D. Institute of medicine
Answer: C. State Nurse Practice Act

36. A charge nurse observe a licensed practical nurse tell a client that she will return with a
medication to help relieve the client’s nausea. The LPN does not return with the medication.
The charge nurse should reinforce which of the following ethical principles with the LPN?
A. Veracity
B. Justice
C. Fidelity
D. Nonmaleficence
Answer: C. Fidelity

37. A nurse administrator is using benchmarking as control criteria while reviewing current
policies and procedures. Which of the following actions should the nurse take?
A. Use root cause analysis to identify gaps in meeting standards- root cause analysis is done
if the benchmark is not met
B. Establish work initiatives to promote a positive environment
C. Compare practices within the facility against other high-performing facilities
D. Determine how current practice will affect future performance within the facility
Answer: C. Compare practices within the facility against other high-performing facilities
38. A nurse enters a client’s room and identifies that the client is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the
nurse take first?
A. Place a faulty equipment tag on the pump
B. Notify the provider
C. Auscultate the client’s lungs
D. Complete an incident report

Answer: C. Auscultate the client’s lungs

39. A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the
surgical suite. Which of the following nursing statements is an appropriate nursing response?
A. “It’s not too late to cancel the surgery if you want to”
B. “Why did you make the decision to have this procedure?”
C. “This won’t take long and it will be over before you know it”
D. “You shouldn’t be worried because the procedure is very safe”
Answer: A. “It’s not too late to cancel the surgery if you want to”

40. A facility infection control nurse is reviewing the reports of a group of clients. Which of
the following infections should the nurse report to the public health department?
A. Lyme disease
B. Bacterial conjunctivitis
C. Health care-acquired pneumonia
D. MRSA
Answer: A. Lyme disease

41. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility.
Which of the following information should the nurse include in the change-of-shift report?
A. The steps to follow when providing wound care
B. The client’s preferred time for bathing
C. The belief that the client has a difficult relationship with his son
D. The time the client received his last dose of pain medication
Answer: D. The time the client received his last dose of pain medication
42. A nurse receives a new prescription over the telephone from a client’s provider. Which of
the following actions should the nurse take first
A. Write down the complete prescription
B. Read back the prescription to the provider
C. Document the prescription as a telephone prescription in the medical record
D. Ensure that the provider signs the prescription
Answer: B. Read back the prescription to the provider

43. A charge nurse witnessed an assistive personnel failing to follow facility protocol when
discarding contaminated linens. Which of the following actions should the nurse take first?
A. Discuss the issue with the AP
B. Notify the unit manager about the incident
C. Reinforce facility protocols at the next staff meeting
D. Alert the infection control department
Answer: A. Discuss the issue with the AP

44. A nurse is planning care for a client who is disoriented and has a history of wandering.
Which of the following actions should the nurse include in the plan?
A. Raise all four side rails on the client’s bed
B. Remove the clock and calendar from the client’s room
C. Obtain a prescription for a sedative for the client
D. Provide distractions for the client during the day
Answer: D. Provide distractions for the client during the day

45. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the
following actions should the nurse take?
A. Initiate contact precautions (standard)
B. Report the infection to the local health department
C. Apply an antiviral cream to lesions
D. Instruct the client to use condoms until the treatment is completed (NO, not 100%
preventable)
Answer: B. Report the infection to the local health department

46. A nurse is teaching a class of newly licensed nurses about evidence-based practices. The
nurse should include which of the following as the first step in evidence-based practice?
A. Apply research to client care practice
B. Develop a clinical question
C. Critically assess the evidence
D. Collect evidence from a variety of sources
Answer: B. Develop a clinical question

47. A nurse assumes the leading role on the hazardous materials team immediately following
a chemical mass casualty incident in the community. As clients arrive at the designed triage
area outside the hospital, which of the following actions should the nurse take?
A. Place shower caps over the client's’ hair
B. Remove contaminated clothing
C. Scrub the client’s skin with betadine solution
D. Admit the injured clients to positive-pressure rooms
Answer: B. Remove contaminated clothing

48. A case manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse
manager should identify that which of the following torts has occurred?
A. Libel
B. Negligence
C. Battery
D. Slander
Answer: A. Libel

49. A nurse is preparing to complete morning assignments on several assigned clients. Which
of the following clients should the nurse plan to assess first?
A. A client who had a bladder scan that indicated 250 mL of urine in the bladder
B. A client who is 3 days postoperative and who’s dressing has serosanguinous drainage
C. A client who has diabetes and an early morning blood glucose of 220 mg/dL
D. A client who has a nasogastric tube to intermittent suction and reports nausea
Answer: D. A client who has a nasogastric tube to intermittent suction and reports nausea
50. A charge nurse overhears a staff nurse discussing a client’s diagnosis in the cafeteria.
Which of the following responses should the charge nurse make?
A. “Please stop discussing the client in a public area”
B. “Do you understand the HIPAA regulations?”
C. “We should discuss your concerns with the client’s care team”
D. “I will notify the client’s provider about this breach of confidentiality
Answer: A. “Please stop discussing the client in a public area”

51. A nurse preceptor is observing a newly hired nurse perform a sterile dressing change.
Which of the following actions should the nurse preceptor identify as maintaining sterile
technique?
A. Places sterile gauze 1.3cm (0.5 in) away from the edge of a sterile drape
B. Uses sterile forceps to pack sterile gauze into the wound
C. Sets up the sterile field 30 min prior to performing the dressing change
D. Uses a sterile-gloved hand to adjust the back of the sterile gown.
Answer: B. Uses sterile forceps to pack sterile gauze into the wound

52. A nurse working in a long-term care facility is assessing an older adult client who has
been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the
following actions should the nurse take?
A. Place the client in a negative-pressure airflow room
B. Perform hand hygiene with alcohol based hand sanitizer.
C. Clean the equipment in the client’s room with bleach.
D. Initiate droplet precautions for the client.
Answer: C. Clean the equipment in the client’s room with bleach.

53. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse
is having trouble focusing and has difficulty completing care for his assigned clients. Which
of the following interventions is appropriate?
A. Advise him to complete the less time consuming tasks first
B. Recommend that he take time to plan at the beginning of his shifts
C. Offer to provide care for his clients while he take a break
D. Ask other staff members to take over some of his tasks
Answer: B. Recommend that he take time to plan at the beginning of his shifts

54. A nurse is planning discharge for a client who has lung resection. The nurse initiates a
referral for a social worker. Which of the following assessment data supports this referral?
A. The client needs to have someone bring O2 tanks and equipment to her home
B. The client needs to have range-of-motion exercises to assist with ambulation
C. The client needs to arrange financial resources to purchase equipment
D. The client needs to have someone come in to help her bathe at home
Answer: C. The client needs to arrange financial resources to purchase equipment

55. A nurse initiates a referral to an occupation therapist for a client who has rheumatoid
arthritis. Which of the following assessment findings supports the need for this referral?
A. The client reports pain when chewing solid foods.
B. The client expresses the desire to join a support group.
C. The client requires assistance with completing oral hygiene
D. The client has difficulty ambulating with a walker
Answer: C. The client requires assistance with completing oral hygiene

56. A nurse is caring for a client who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted in regard to this client’s care? (SATA)
A. Nutritional therapists
B. Case Manager
C. Mental Health counselor
D. Occupational therapist
E. Physical therapist
Answer: A. Nutritional therapists
B. Case Manager
C. Mental Health counselor

57. A nurse is prioritizing care after a receiving change-of-shift report on four clients. Which
of the following clients should the nurse assess first? [repeat]
A. A client who reports a headache with sensitivity to light.
B. A client who reports feeling lightheaded when he stands up from a lying position
C. A client who reports indigestion and pain in her jaw
D. A client who reports an urge to void but has not urinated during the prior shift
Answer: C. A client who reports indigestion and pain in her jaw

58. A nurse on an acute mental health unit is assessing four clients. Which of the following
clients is the highest priority?
A. A client who has depressive disorder and has poor personal hygiene
B. A client who has dementia and exhibits aphasia
C. A client who has bipolar disorder and displays constant pacing – (Can lead to physical
exhaustion and death)

D. A client who has schizophrenia and uses neologisms
Answer: C. A client who has bipolar disorder and displays constant pacing – (Can lead to
physical exhaustion and death)

59. A nurse is planning care for a group of clients. Which of the following action should the
nurse take first?
A. Obtain a breakfast tray for a client whose total parenteral nutrition was discontinued 4 hrs
ago.
B. Auscultate the bowel sounds of a client who has not had bowel movement after taking a
laxative 12hr ago.
C. Provide instruction to the caregiver of a client who has dementia and new diagnosis of
diabetes mellitus.
D. Check a client who has a leg cast and reports a new onset of pain.
Answer: D. Check a client who has a leg cast and reports a new onset of pain.

60. A nurse on a medical surgical unit is caring for a client who asks about advance directives
and states that he wants to appoint a health care proxy. Which of the following responses
should the nurse make?
A. “You must choose a member of your family to serve as a your health care proxy.”
B. “A health care proxy can make decisions for you when you are unable to do so.”
C. “You should appoint a health care proxy before undergoing an invasive procedure.”
D. “It is necessary for an attorney to approve your health care proxy.”
Answer: B. “A health care proxy can make decisions for you when you are unable to do so.”

61. A nurse in a rehabilitation facility is administering medications to a client who was
admitted earlier that day. The client refuses two of the medications, stating, “I’ve never taken
these before.” Which of the following actions should the nurse take first?
A. Consult the pharmacist about the client’s prescribed medications.
B. Compare the client’s medication administration record with the prescriptions on the
transfer orders.
C. Review the intended purpose of the prescribed medication with the client.
D. Call the provider to clarify the clients prescribed medications.
Answer: B. Compare the client’s medication administration record with the prescriptions on
the transfer orders.

62. A nurse on a med surgical unit is caring for four clients. The nurse should recognize that
which of the following clients is the highest priority?
A. A client who is postoperative following laminectomy 12hrs ago is unable to void
B. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy
C. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38C (101F)
Answer: C. A client who has peripheral vascular disease and has an absent pedal pulse in the
right foot

63. A nurse in the emergency department admits a client who has been exposed to cutaneous
anthrax.
Which of the following actions should the nurse take?
A. Plan to administer an antiviral medication to the client.
B. Wear an N95 respirator mask while caring for the client.
C. Prepare to administer antibiotics to the client.
D. Place a surgical mask on the client during transfer to the unit.
Answer: C. Prepare to administer antibiotics to the client.

64. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts.
Which of the following actions should the nurse take first?
A. Discuss the time management strategies with the nurses
B. Review facility policies for taking scheduled breaks.
C. Provide coverage for the nurses’ breaks
D. Determine the reasons the nurses are taking scheduled breaks.
Answer: D. Determine the reasons the nurses are taking scheduled breaks.

65. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse
distracts the client and quickly administers the injection. This illustrates which of the
following?
A. False imprisonment
B. Libel

C. Assault
D. Battery
Answer: D. Battery

66. A nurse is speaking with a visitor who asks a questions about the status of a relative who
is a fado client on the unit. Which of the following responses by the nurse is appropriate?
A. “I’m not taking care of your relative today, so I don’t have the latest information”
B. “I will have your relative’s nurse come and talk with you about her care.”
C. “Let me check your relative’s medical record to see how she’s doing.”
D. “Please ask your relative about this, because I cannot share information about her.”
Answer: D. “Please ask your relative about this, because I cannot share information about
her.”

67. A nurse suggests respite care for the partner of a client who has mild cognitive
impairment. The client’s partner asks the nurse how that would help. The nurse should
explain the respite care would do which of the following?
A. Allow her to take time off from attending to her partner
B. Provide volunteers who will run errands for her
C. Send a clinician to assess the safety of leaving her partner alone
D. Help her arrange transferring her partner to an assisted living facility
Answer: A. Allow her to take time off from attending to her partner

68. A charge nurse observes a client fall during ambulation and notes that his gait belt was not
in place. In reviewing the incident report, the nurse finds no mention of a gait belt. Which of
the following ethical principles should guide the nurse’s subsequent actions?
A. Non maleficence - do no harm
B. Veracity - commitment to tell the truth
C. Fidelity - keep promises
D. Beneficence - promote good for others
Answer: B. Veracity - commitment to tell the truth

69. A nurse is caring for a client who is scheduled for placement of a central venous access
device. Which of the following actions is the nurse’s responsibility in the informed consent
process?

A. Place a photocopy of the signed consent in the client’s medical record
B. Review the risks and benefit of the procedure with the client
C. Discuss alternative treatment options with the client
D. Assess the client’s understanding after the provider has talked with her
Answer: D. Assess the client’s understanding after the provider has talked with her

70. A nurse is providing teaching to an assistive personnel about the application of wrist
restraints to a client. Which of the following instructions should the nurse include in the
teaching?
A. Remove the client’s restraints every 2 hr.
B. Allow 1 fingerbreadth between the restraint and the client’s wrists
C. Attach the restraints to the fixed portion of the frame of the client’s bed
D. Secure the client’s restrains with a square knot
Answer: C. Attach the restraints to the fixed portion of the frame of the client’s bed

1. A nurse is preparing an educational program for staff members 2 a new intravenous pump.
Identify the sequence of actions the nurse should taken when developing the program. (Move
the steps into the box on the right, placing them in order of performance).
A. Determine what skills to teach the staff members
B. Develop learning objectives for the program
C. Identify resources available to meet objectives
D. Review the staff member’s evaluation of the program
Answer:

1. A nurse suggest respite care for the partner of a client who has mild impairment. The
client’s partner asks the nurse how that would help. The nurse should explain that respite care
would do which of the following?
Answer: • Allow her to take time off attending to her partner

2. A case manager observes a family member of a client who has Alzheimer’s disease
throwing books on the floor and sobbing while the client is having a diagnostic test. Which of
the following actions should the case manager take first?
Answer: • Offer to have a brief talk with the caregiver
3. A nurse is caring for a client who has early stage Alzheimer’s disease. In which of the
following actions is the nurse acting as a client advocate?
Answer: • Requesting a referral for the client to attend reminiscent therapy sessions

4. A nurse manager is reviewing the nursing code of ethics with the staff nurses. Which of the
following statements by a staff nurse indicate understanding of the teaching (SATA).
Answer: • “I will attend continuing education classes for professional growth.”
• “I can delegate the removal of an IV catheter to an LPN on the unit.”
• “I administer pain medication to my clients even if they have a history of narcotic
addiction.”

6. A nurse is discussing advance directives with a client. Which of the following statements
by the client indicates an understanding of advance directives?
Answer: • “I know I have the right to determine if I remain on a breathing machine.”

7. A nurse is caring for a client who has a pressure ulcer on the coccyx. Which of the
following findings indicated the need for referral to a wound care specialist?
Answer: • Presence of slough in the wound bed

8. A nurse on a medical-surgical unit delegating client care. Which of the following tasks
should the nurse delegate to an assistive personnel?
Answer: • Suctioning a client’s long-term tracheostomy

9. A nurse is providing teaching about infection control measures to a client who has an
indwelling urinary catheter. Which of the following instructions should the nurse include in
the teaching?
Answer: • Use sterile technique to collect specimens from the drainage system

10. A nurse manager is preparing an in-service for a group of staff nurses about organ
donation. Which of the following information should the manager include?
Answer: • Nurses may witness the signing of organ donation consents

11. A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the
surgical suite. Which of the following nursing statements is an appropriate nursing response?
Answer: • “It’s not too late to cancel the surgery if you want to.” [repeat]

12. A charge nurse is observing a newly licensed nurse insert an NG tube and connect it to a
suction source. Which of the following actions by the newly licensed nurse demonstrates an
understanding of the process?
Answer: • Clamps the air vent tubing

13. A nurse working in an emergency department is performing triage. To which of the
following clients should the nurse assign priority?
Answer: • A client who has soot markings around each naris following a house fire

14. A nurse receives change-of-shift report for the following four clients. Which of the
following clients should the nurse assess first?
Answer: • An older adult client who has bacterial pneumonia and a new onset of restlessness

15. A charge nurse is making assignments for a medical surgical unit. Which of the following
clients is appropriate to assign to a licensed practical nurse?
Answer: • A client who has emphysema and has oxygen saturation of 92%

16. A nurse is admitting a client who is scheduled for cholecystectomy. The client does not
speak English and is accompanied by her adult daughter. Which of the following actions
should the nurse take?
Answer: • Access a language line to interpret what is being said
17. A nurse is caring for a client who has an MI. The client’s daughter ask the nurse to review
her father’s medical with her. Which of the following responses should the nurse make?
Answer: • “Your father will have to give permission for you to review the record.”

18. A nurse is teaching a client who requires protective isolation due to immune system
compromise. Which of the following instructions should the nurse include to protect the
client?
Answer: “Make sure your visitors wear a gown when they are in your room.”
“Wear gloves and a gown whenever you need to leave your room.”
“Be sure to eat plenty of fresh fruit and vegetables.”

19. A nurse in the emergency department is preparing a married 17-year-old client for an
appendectomy. The client’s parents are en route to the facility but have not spoken with the
surgeon. Which of the following actions should the nurse take?
Answer: • Have the client sign the consent form after the surgeon explains the procedure

20. A nurse is preparing a client for surgery. The client has signed the consent form but tells
the nurse that she has reconsidered because she is worried about the pain. Which of the
following responses by the nurse is appropriate?
Answer: • “I understand, and it’s not too late to change your mind.”

21. A nurse is completing discharge teaching with a client who is being treated with
tuberculosis (TB). Which of the following statements by the client indicates an understanding
of the teaching?
Answer: • “I should have a sputum culture done every 2-4 weeks”

22. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following to manage the
tracheostomy at home? (SATA)
Answer: • Obturator
• Oxygen tank
• Suction machine

23. A nurse is completing discharge teaching about dietary supplements for nitrogen loss with
a client who has cancer. Which of the following nutrients should the nurse recommend the
client increase?
Answer: • Protein

24. A case manager is preparing a client who has a spinal cord injury for discharge from the
rehabilitation setting to home. Which of the following actions is the case manager’s priority
when creating the discharge plan?
Answer: • Facilitate client referrals for community resources

A nurse is chairing a committee about preventing infant abduction in a new birth care center.
Which of the following quality control tasks should the nurse assign to be completed first?
A. Establish measurement criteria for infant safety systems.
B. Evaluate the selected infant safety system.
C. Choose an infant safety system.
D. Identify the industry standards for infant safety.
Answer: D. Identify the industry standards for infant safety.

A nurse at a local health department is caring for four clients who have communicable
diseases. Which of the following infections should the nurse report to the state health
department?
A. Chlamydia trachomatis
B. Pediculosis capitis
C. Impetigo contagiosa
D. Candida albicans
Answer: A. Chlamydia trachomatis

A nurse at a clinic is teaching a newly licensed nurse about sexually transmitted infections.
The nurse should instruct the newly licensed nurse to report which of the following infections
to the health department.
A. Candidiasis
B. Gonorrhea
C. Trichomoniasis
D. Human papillomavirus
Answer: B. Gonorrhea

A charge nurse discovers that a staff nurse on the unit has made repeated medication errors.
Which of the following actions should the charge nurse take first?
A. Review with the nurse principles of medication administration.

B. Ask the nurse to describe the medication administration procedure.
C. Identify education opportunities for the nurse regarding safe medication administration.
D. Notify the risk management department of the situation.
Answer: C. Identify education opportunities for the nurse regarding safe medication
administration.

The family members of an older adult client are expressing conflict over whether the client
should have surgery that is recommended by the provider. The oldest adult child has durable
power of attorney for health care for the client. The client is oriented to person, place, and
time. Which of the following people has the legal authority to make the health care decision?
A. The provider
B. The oldest adult child
C. The partner
D. The client
Answer: D. The client

A nurse is working with a committee that is performing an annual review of policies and
procedures. After gathering data, identify the sequence the committee should follow when
using the stages of change. (put in order)
A. Determine goals
B. Create a revised protocol
C. Implement the revised protocol
D. Review the results of the provisions.
Answer: A. Determine goals 1
B. Create a revised protocol 2
C. Implement the revised protocol 3
D. Review the results of the provisions. 4

A nurse is providing a change of shift report for the oncoming nurse. Which of the following
information should the nurse include in the report?
A. “ The client’s partner came to visit him 2 hours ago and smelled of alcohol.”
B. “ The client is the president of a local bank.”
C. “ The client will need vital signs checked every 4 hours.”
D. “ The client is currently in the radiology department for a chest x-ray.”

Answer: D. “ The client is currently in the radiology department for a chest x-ray.”

A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of
asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which
of the following referrals should the nurse recommend?
A. Child protective services
B. Pharmacist
C. Social worker
D. Respiratory therapist
Answer: C. Social worker

A nurse is preparing a shift assignment for an assistive personnel on the unit. Which of the
following tasks should the nurse assign to the AP?
A. Check a client’s pain level 30 min after receiving acetaminophen
B. Administer the initial bolus feeding to a client who has an NG tube
C. Collect a urine specimen from a newly admitted client
D. Instruct a client to splint an abdominal incision
Answer: C. Collect a urine specimen from a newly admitted client

A nurse is teaching a class of newly licensed nurses about evidence- based practice. The
nurse should include which of the following as a first step in evidence-based practice.
A. Collect evidence from a variety of sources
B. Develop a clinical question
C. Apply research to client care practice
D. Critically assess the evidence
Answer: B. Develop a clinical question

A nurse is inspecting a clients IV pump prior to use. The nurse should tag and report which of
the following safety hazards?
A. The electrical cord is taped to the floor
B. The IV pump is plugged into an outlet close to the bed
C. The IV pump has a free-flow protective device
D. The electric plug has two short prongs – (Must be 3 prongs)
Answer: D. The electric plug has two short prongs – (Must be 3 prongs)

A nurse who is caring for a group of clients, delegates collection of vital signs to an assistive
personnel. Which of the following actions should the nurse take to evaluate the delegated
task?
A. Recheck vital signs that are outside the expected reference range
B. Review the vital sign trends at the end of the shift.
C. Ask the AP to write a summary of the delegated tasks during the shift.
D. Compare the vital signs the AP obtained with those taken by another AP on a previous
shift.
Answer: A. Recheck vital signs that are outside the expected reference range

A nurse is caring for a client who has signed consent for the removal of the tumor in the left
frontal lobe of the brain. The client states, “The tumor is on the right side of my head.” Which
of the following actions should the nurse take?
A. Continue with the surgery because the client already gave informed consent.
B. Ask the surgeon to clarify the operative site with the client

C. Contact the surgery department to validate the operative site
D. Tell the client to mark the right side of his head with indelible ink
Answer: B. Ask the surgeon to clarify the operative site with the client
A nurse is preparing to witness a client’s signature on an informed consent for a surgical
procedure. Which of the following actions is the nurse’s responsibility?
A. Ensuring the client appears competent to consent to the procedure
B. Discussing options for the alternative therapies with the client
C. Providing the client with a complete description of the procedure
D. Explaining the risks associated with the procedure to the client
Answer: A. Ensuring the client appears competent to consent to the procedure
A charge nurse witnesses two nurses having a loud discussion at the nurses’ station about not
wanting to care for a client who has drug-resistant tuberculosis. Which of the following
actions should the charge nurse take?
A. Make arrangements to take over the clients care.
B. Contact the house supervisor to mediate the conflict
C. Escort the nurses to the nurses lounge to continue the discussion
D. Recommend that both nurses are terminated
Answer: C. Escort the nurses to the nurses lounge to continue the discussion

A nurse is observing an assistive personnel administer 0.9% sodium chloride enema to an
adult client. For which of the following actions by the AP should the nurse intervene?
A. Inserts the tubing 8 cm (3.1 in) into the rectum
B. Positions the client on her left side with knees flexed
C. Points tubing in the direction of the umbilicus during insertion
D. Administers the solution at room temperature
Answer: B. Positions the client on her left side with knees flexed

A nurse is prioritizing care after receiving report on four clients. Which of the following
clients should the nurse assess first?
A. A client who reports feeling lightheaded when he stands up from a lying position
B. A client who reports an urge to void but has not urinated during the shift prior
C. A client who reports indigestion and pain in her jaw

D. A client who reports a headache with sensitivity to light
Answer: C. A client who reports indigestion and pain in her jaw

A charge nurse is directing the unit nurses to implement the emergency response plan for a
fire on the unit.
Which of the following instructions should the charge nurse give to the unit nurses?
A. Ask ambulatory clients to help move clients in wheelchairs to safety
B. Continue therapy for clients who are receiving oxygen
C. Close the doors of the unit before moving clients to a safe place
D. Maintain mechanical ventilation for clients who are on life support.
Answer: B. Continue therapy for clients who are receiving oxygen

A nurse is providing teaching to an older adult client regarding home safety. Which of the
following instructions should the nurse include in the teaching?
A. Cover chords with the carpet to prevent falls
B. Unplug humidifier before cleaning it
C. Change batteries in the smoke alarm every 2 years
D. Set the water heater to 60 degrees C (140 F)
Answer: B. Unplug humidifier before cleaning it

A nurse is using the SBAR communication tool while giving report on a client. The nurse
should include the client’s pain level after receiving a PRN dose of morphine 1 hr ago during
which part of the report?
A. A-assessment
B. B-background
C. R-recommendation
D. S-situation
Answer: A. A-assessment

A nurse is comparing the rate of medication errors on the medical unit to the rate from a
medical unit in a magnet hospital. Which of the following quality improvement methods is
the nurse using?
A. Benchmarking
B. Structure audit

C. Risk benefit analysis
D. Root cause analysis
Answer: A. Benchmarking

A nurse is planning a discharge for a client who has a new diagnosis of COPD and lives
alone. Which of the following actions is the nurse’s priority?
A. Provide printed materials for new prescriptions
B. Set up appointments in in-home physical therapy
C. Request a referral for a home safety assessment
D. Suggest participating in a community group
Answer: C. Request a referral for a home safety assessment

A nurse is caring for a group of clients. Which of the following clients should the nurse see
first?
A. A client who is postoperative and has a fever (nonurgent)
B. A client who has a fractured hip and reports a pain level of 7 on a scale of 0 to10
C. A client who has pressure ulcer has serosanguineous drainage on the dressing
D. A client who has diabetes mellitus and is diaphoretic
Answer: D. A client who has diabetes mellitus and is diaphoretic

A nurse manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a client as an HIV-positive due to multiple sexual partners. The nurse
manager should identify that which of the following torts has occurred?
Negligence
A. Battery
B. Libel
C. Slander
Answer: B. Libel

A nurse initiates a referral to an occupational therapist for a client who has rheumatoid
arthritis. Which of the following assessment findings supports the need for the referral?
A. The client has difficulty ambulating with a walker
B. The client requires assistance with completing oral hygiene
C. The client reports pain when chewing on solid foods

D. The client expresses desire to join a support group
Answer: B. The client requires assistance with completing oral hygiene
A home health nurse finds piles of newspaper in the hallway of a client’s home. The nurse
explains the need to discard the newspapers for safety reasons. The client agrees to move the
newspapers into the living room. Which of the following conflict resolution strategies has the
nurse used?
A. Compromising
B. Smoothing
C. Collaborating
D. Accommodating
Answer: D. Collaborating
A nurse reports to a charge nurse that a client’s visitor slipped and fell. The visitor denies any
injury and is walking around. Which of the following instructions should the charge nurse
give the nurse?
A. “ Have the visitor sign a waiver”
B. “ Document the incident report in the client’s medical record”
C. “Offer the visitor an analgesic”
D. “ Record the event on an occurrence report”
Answer: D. “ Record the event on an occurrence report”

A nurse is preparing an education program about professional codes of ethics for nurses.
Which of the following information should the nurse plan to include?
A. A code of ethics is a step-by-step approach to decision making
B. A code of ethics is legally binding
C. A code of ethics outlines the nurses scope of practice
D. A code of ethics is a set of principles for nursing practice
Answer: C. A code of ethics outlines the nurses scope of practice

An infection control nurse is planning an education program for a group of newly licensed
nurses. Which of the following infections should the nurse include when discussing illnesses
requiring droplet precautions?
A. Rotavirus

B. Rubeola
C. Varicella
D. Mumps
Answer: D. Mumps

A nurse manager discovers there is a conflict between nurses working day shift and working
night shift.
Which of the following actions should the nurse take?
A. Gather information regarding the situation
B. Acknowledge the conflict and encourage the nurses to focus on working as a team
C. Encourage the nurses to resolve the conflict autonomously
D. Meet with the a committee of nurses from each shift to discuss issues related to the
conflict
Answer: A. Gather information regarding the situation

A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After
donning a sterile gown and gloves, which of the following actions by the newly licensed
nurse demonstrates correct aseptic technique?
A. The nurse puts on a face mask
B. The nurse applies goggles
C. The nurse holds her hands above her waist
D. The nurse turns her back to the sterile field
Answer: C. The nurse holds her hands above her waist

A nurse in an emergency department is triaging four clients. Which of the following clients
should the nurse recommend to be examined first?
A. An adolescent who has an injured ankle and reports a pain level of 8 on a scale of 0-10
B. A toddler who has a 2cm (0.79 in) head laceration oozing dark red blood
C. An older adult client who has dyspnea and a respiratory rate of 26min
D. An adult client who has large ecchymoses on both legs
Answer: C. An older adult client who has dyspnea and a respiratory rate of 26min

A nurse is caring for a client who has a prescription for transcutaneous electrical nerve
stimulation (TENS). Which of the following members of the interdisciplinary team should
the nurse contact for assistance?
A. Pharmacist
B. Occupational therapist
C. Respiratory therapist
D. Physical therapist
Answer: D. Physical therapist

A nurse in a long-term care facility is planning a fall prevention program for the residents.
Which of the following interventions should the nurse include?
A. Accompany residents older than 85 years of age during ambulation
B. Institute rounds every 2 hr during the day to offer toileting
C. Keep the four side rails up on beds at night
D. Apply vest restraints on residents who are confused
Answer: B. Institute rounds every 2 hr during the day to offer toileting

A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of
the following information should the nurse include in the change of shift report?
A. The time the client received his last dose of pain medication
B. The clients preferred bath time
C. The belief that the client has a difficult relationship with his son
D. The steps to follow when providing wound care
Answer: A. The time the client received his last dose of pain medication

A nurse is caring for four clients who are scheduled to undergo surgery. Which of the
following clients can give informed consent?
A. An adult client who has moderate Alzheimer’s disease
B. An older adult client who has questions about the procedure
C. An adult client who has alcohol intoxication
D. An adolescent client who is legally emancipated
Answer: D. An adolescent client who is legally emancipated

A nurse is completing a performance evaluation for an assistive personnel. Which of the
following actions by the AP requires intervention by the nurse?
A. The AP wears a mask when caring for a client who has varicella
B. The AP removes cut flowers from the room of a client who is in a protective environment
C. The AP closes the door of a client who is on airborne precaution
D. The AP uses alcohol hand antiseptic after caring for a client who has C-Diff
Answer: D. The AP uses alcohol hand antiseptic after caring for a client who has C-Diff

A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
A. A young adult client who is participating in a medical research study
B. An older adult client who has advance directives on file
C. An adolescent client whose parents refuse a blood transfusion for religious reasons
D. A middle adult client who leaves the facility against medical advice
Answer: C. An adolescent client whose parents refuse a blood transfusion for religious
reasons

A nurse is working with a licensed practical nurse (LPN) to care for a group of clients. Which
of the following clients should the nurse delegate to the LPN?
A. A client who has leukemia and requires an updated plan of care
B. A client who is transferring from the PACU following abdominal hernia repair
C. A client who has type 1 diabetes mellitus and receives insulin before meals
D. A client who requires discharge teaching about a newly described medication
Answer: C. A client who has type 1 diabetes mellitus and receives insulin before meals

A nurse is coordinating an interprofessional team to review proposed standards to reduce the
transmission of MRSA. Which of the following members of the interprofessional team
should the nurse consult?
A. Infection control nurse
B. Nursing supervisor
C. Risk management coordinator
D. Clinical pharmacist
Answer: A. Infection control nurse

A charge nurse provides an annual in-service for the nursing staff regarding ethical practice.
Which of the following actions should the nurse include as an example of ethical practice?
A. A nurse raises all four side rails on the bed of a client who is confused
B. A nurse refuses to care for a client who has had an abortion
C. A nurse withholds nutrition from a client who has DNR order - don’t do this...
D. A nurse administers prescribed opioids to a client who has a terminal illness and
respiratory rate of 8/min.
Answer: D. A nurse administers prescribed opioids to a client who has a terminal illness and
respiratory rate of 8/min.

A nurse is conducting an in service about the nursing code of ethics with a group of newly
licensed nurses. Which of the following information should the nurse include in the teaching
as an example of advocacy?
A. Evaluating a client’s home for safety hazards
B. Recommending a referral for a client who requires physical therapy
C. Completing an incident report following a medication error
D. Suggesting a client’s partner attend a support group for emotional support
Answer: B. Recommending a referral for a client who requires physical therapy
A nurse enters a client’s room and identifies that the client is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the
nurse take first?
A. Notify the provider
B. Place a faulty equipment tag on the pump
C. Auscultate the client’s lungs
D. Complete and incident report
Answer: C. Auscultate the client’s lungs

A nurse is documenting and completing an incident report after a client falls out of bed.
Which of the following actions should the nurse take when completing the documentation?
A. Document in the incident report, ‘ Entered room and discovered client lying prone on the
floor’
B. Document in the nurses report, ‘Photocopy of incident report sent to risk management’
C. Document in incident report, ‘Client found lying on the floor after falling out of bed’

D. Document in nurses notes, ‘Incident report completed and filed’
Answer: C. Document in incident report, ‘Client found lying on the floor after falling out of
bed’

A nurse is planning discharge teaching for a client who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following supplies to manage
tracheostomy at home? (SATA)
A. Cotton-twill tracheostomy ties
B. Suction machine
C. Povidone – iodine swabs
D. Petroleum jelly lubricated gauze
E Oxygen tank
Answer: E Oxygen tank

A nurse is providing discharge teaching to a client following total knee arthroplasty. Which of
the following information should the nurse include? (SATA)
A. Information about follow up care
B. Medication guideline information
C. Advance directives information
D. Contact information for the physical therapist
E. Insurance information
Answer: A. Information about follow up care
B. Medication guideline information
D. Contact information for the physical therapist
A charge nurse overhears a staff nurse discussing a client’s diagnosis in the cafeteria. Which
of the following responses should the charge nurse make?
A. “ We should discuss your concerns with the client’s care team”
B. “ I will need to notify the client’s provider about the breach of confidentiality”
C. “ Please stop discussing the client in a public area”
D. “ Do you understand HIPAA regulations?”
Answer: C. “ Please stop discussing the client in a public area”

A nurse is caring for a client who reports taking a new herbal supplement after reading about
it on the Internet. Which of the following instructions should the nurse provide the client?
A. Compare website’s information with a variety of sources
B. Look for medical information on network (. Net) websites
C. Ensure the website is sponsored by a pharmaceutical company
D. Consider the Internet information reliable if it is written by a doctor
Answer: D. Consider the Internet information reliable if it is written by a doctor

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain
that preventing client injury by removing a fall hazard demonstrates which of the following
ethical principles?
A. Veracity – nurse’s duty to tell the truth
B. Nonmaleficence – nurse’s obligation to avoid causing harm to the client
C. Utility
D. Autonomy – the ability of the client to make personal decisions
Answer: B. Nonmaleficence – nurse’s obligation to avoid causing harm to the client

A nurse is preparing a client for surgery. The client expresses concern that someone might
steal her purse during the procedure. Which of the following actions should the nurse take?
A. Tell the client to leave her purse in a drawer of the bedside table
B. Place the purse in the clothing bag with the clients belongings
C. Offer to place the purse in the facility’s safe
D. Offer to store the purse in the nurses station
Answer: C. Offer to place the purse in the facility’s safe

A staff nurse is supervising a newly licensed nurse who is preparing to administer an
intermittent tube feeding to a client. Which of the following actions by the newly licensed
nurse is appropriate?
A. Elevating the head of the bed 20 degree angle
B. Check residual volume before each feeding
C. Flushing The tube with 15 mL of water
D. Adding colored food dye to the formula
Answer: B. Check residual volume before each feeding

A home health nurse is assessing the home environment during an initial visit to a client who
has a history of falls. Which of the following findings should the nurse identify as increasing
the client’s risk of falls? (SATA)
A. A throw rug covering some cracked vinyl flooring in the kitchen
B. A folding chair without arm rests
C. A two- wheeled walker used to assist the client with ambulation
D. A raised vinyl seat on the toilet in the client’s bathroom
E. A wheeled office chair at the client’s computer desk
Answer: A. A throw rug covering some cracked vinyl flooring in the kitchen
B. A folding chair without arm rests
E. A wheeled office chair at the client’s computer desk

A nurse on a medical- surgical unit is caring for a client who asks about advance directives
and states the he wants to appoint a health care proxy. Which of the following responses
should the nurse make?
A. “ It is necessary for an attorney to approve your health care proxy”
B. “ A health care proxy can make decisions for you when you are unable to do so”
C. “ You must choose a member of your family to serve as your health care proxy”
D. “ You should appoint a health care proxy before undergoing an invasive procedure”
Answer: B. “ A health care proxy can make decisions for you when you are unable to do so”

A nurse is preparing to transfer a client to the radiology department using the wheelchair.
Which of the following actions should the nurse take?
A. Push the wheelchair into the elevator, large wheels last/
B. Leave a transfer belt in place until the client returns from radiology
C. Keep the footplates lowered throughout the transfer process.
D. Test the locks on both wheels of the chair prior to transfer.
Answer: D. Test the locks on both wheels of the chair prior to transfer.

A nurse is providing an in-service about client rights for a group of nurses. Which of the
following statements should the nurse include in the in-service?
A. “A nurse can apply restraints on a PRN basis”
B. “A nurse can administer medications without consent to a client as part of a research
study” Patients have right to refuse

C. “A nurse can disclose information to a family member with the client’s permission.”
D. “A nurse is responsible for informing clients about treatment options”
Answer: C. “A nurse can disclose information to a family member with the client’s
permission.”

A charge nurse suspects that a staff nurse is chemically impaired. Which of the following
actions should the charge nurse take?
A. Assign clients who are not prescribed narcotics to the staff nurse
B. Counsel the staff nurse about substance abuse use
C. Collect data about the staff nurse to support further action Always assess first
D. Report the staff nurse to the facility ethics committee
Answer: C. Collect data about the staff nurse to support further action Always assess first

A charge nurse is admitting a client who speaks a different language than the nurse and will
require and interpreter. Which of the following actions should the nurse plan to take?
A. Limit interpreter services to daytime hours
B. Repeat the same words to the interpreter if the client does not understand
C. Assign a bilingual staff member to be the interpreter when caring for the client
D. Pause in the middle of the sentence when using an interpreter
Answer: C. Assign a bilingual staff member to be the interpreter when caring for the client
A nurse is caring for a client who has Addison’s disease. Which of the following tasks should
the nurse plan to delegate to an assistive personnel?
A. Explain to the client about a 24hr urine specimen collection RN
B. Determine the client’s muscle strength prior to ambulation RN
C. Decide how often to measure vital signs RN
D. Remind the client to change positions slowly within AP scope
Answer: D. Remind the client to change positions slowly within AP scope

A nurse is caring for a client who had a stroke and is experiencing difficulty swallowing. The
nurse should arrange a referral to which of the following members of the interprofessional
team regarding the client’s condition?
A. Speech pathologist
B. Occupational therapist

C. Physical therapist
D. Social worker
Answer: A. Speech pathologist
• Evaluates and makes recommendations regarding the impact of disorders or injuries on
speech, language, and swallowing

A nurse is planning care for four clients who were classified using a disaster triage tag team
system following a mass casualty event. Which of the following clients should the nurse
identify as priority?
A. A client who has a red tag
B. A client who has a yellow tag (delayed – serious but not life threatening)
C. A client who has a green tag (minor, walking wounded)
D. A client who has a black tag
Answer: A. A client who has a red tag

A nurse is assessing an older adult client who was brought to the emergency department by
his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which
of the following actions should the nurse take?
A. File an incident report
B. Ask the client about his injuries with the son present
C. Treat and discharge the client
D. Ask the client’s son to wait in the waiting room
Answer: D. Ask the client’s son to wait in the waiting room

A charge nurse is reviewing the actions by a nurse following a client fall. Which of the
following actions by the nurse requires intervention by the charge nurse?
Lists names of witnesses to the fall in the incident report
A. Documents in the client’s record, “Incident report was filed”
B. Sends the incident report to risk management
C. Includes the client’s account of the fall in the incident report
Answer: A. Documents in the client’s record, “Incident report was filed”

A nurse on a medical-surgical unit is making staff assignments. Which of the following tasks
should the nurse delegate to an assistive personnel?

A. Pouching a client’s established ostomy
B. Reinforcing teaching with a client about low-sodium diet
C. Demonstrating the use of an incentive spirometer to a client
D. Updating a family member about a client’s condition
Answer: A. Pouching a client’s established ostomy

A nurse is caring for a client who is scheduled for placement of central venous access device.
Which of the following actions is the nurse’s responsibility in the informed consent process?
A. Discuss alternative treatment options with the client
B. Place a photocopy of the signed informed consent in the client’s medical record
C. Assess the client’s understanding after the provider has talked to her
D. Review the risks and benefits of the procedure with the client
Answer: C. Assess the client’s understanding after the provider has talked to her

A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following
statements by the newly licensed nurse indicates an understanding of the teaching?
A. “ A provider can write a prescription for restraints ‘as needed’
B. “ I should tie the restraints using a square knot”
C. “ I need to tie the restraint to the part of the bed frame that moves”
D. “ I will remove the client’s restraints every 4 hours”
Answer: D. “ I will remove the client’s restraints every 4 hours”

A nurse is receiving change of shift report for four clients. Which of the following clients
should the nurse care for first?
A. A client has pneumonia and requires a tracheostomy dressing change
B. A client has a new colostomy and requires discharge teaching
C. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea
D. A client who is 4 hours postoperative following a hernia repair and has pitting edema of
the right leg – (Compartment syndrome)
Answer: D. A client who is 4 hours postoperative following a hernia repair and has pitting
edema of the right leg – (Compartment syndrome)

A charge nurse is receiving change of shift report. Which of the following situations should
the charge nurse report address first?

A. Transport assistance is unavailable to take a client to occupational therapy
B. The emergency department nurse is waiting to give report on a new admission
C. A nurse on the previous shift wrote an incident report on a medication error
D. Two staff members have called to say there were absent
Answer: D. Two staff members have called to say there were absent

A nurse is providing information to a client about advance directives. The nurse should
explain that advance directions include which of the following?
A. Instructions regarding treatments the client desires or does not desire
B. Information regarding organ donation
C. Information regarding the disposition of the client’s body upon death
D. A form with directions for contacting next of kin
Answer: A. Instructions regarding treatments the client desires or does not desire

A nurse is reviewing medication administration record of a client and notices that an
additional dose of medication has been administered. Which of the following actions should
the nurse make first?
A. Inform the nursing supervisor
B. Notify the provider
C. Complete an incident report
D. Observe the client’s condition
Answer: D. Observe the client’s condition

A nurse is assessing a client who has meningitis. Which of the following finding should the
nurse report to the provider immediately?
A. Increased temperature
B. Report of photophobia
C. Decreased level of consciousness
D. Generalized rash over trunk
Answer: C. Decreased level of consciousness

1. A nurse is evaluating a newly licensed nurse who is administering a vitamin K injection to
a newborn. Which of the following actions by the newly licensed nurse indicates
understanding of the teaching? (SATA)

A. Applies gentle pressure at the site after injection
B. Aspirates the syringe for blood return after needle insertion
C. Selects the dorsogluteal site to administer the injection
D. Inserts the needle at a 45° angle - IM should be 90
E. Cleans the injection site with alcohol
Answer: A. Applies gentle pressure at the site after injection
B. Aspirates the syringe for blood return after needle insertion
E. Cleans the injection site with alcohol

2. 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. “The nurse can answer any questions the client has about the procedure.”
D. “A family member can interpret to obtain informed consent from a client who is deaf.”
Answer: B. “Consent can be given by a durable power of attorney.”

3. 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. Obtain the blood sample from the finger pads.
B. Elevate the arm for 1 min before taking the blood sample.
C. Cap the lancet prior to putting it in the trash.
D. Warm the hands prior to piercing the skin
Answer: D. Warm the hands prior to piercing the skin

4. A client is admitted with COPD. Which of the following findings should the nurse report to
the provider?
A. Report of dyspnea on exertion
B. Oxygen saturation 89% on room air
C. White blood cell count 9,000/mm3
D. Bilateral crackles on auscultation of lungs
Answer: D. Bilateral crackles on auscultation of lungs

5. A client schedule for a tubal ligation procedure starts to cry as she is wheeled into the
surgical suite. Which of the following nursing statements is an appropriate nursing response?
A. “You shouldn’t be worried because the procedure is very safe.”
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. “It’s not too late to cancel the surgery if you want to.”
Answer: D. “It’s not too late to cancel the surgery if you want to.”

6. 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. Libel
B. False imprisonment
C. Battery
D. Assault
Answer: C. Battery
7. 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 inservice about client confidentiality.
B. Fill out an incident report regarding the situation.
C. Remind them that client information is confidential.
D. Report the incident to the nursing supervisor.
Answer: C. Remind them that client information is confidential.

8. A nurse is serving on a committee that is revising the protocol for discharging clients. After
developing an initial plan, in which order should the nurse take the following steps?
A. Determine goals
B. Implement recommended strategies
C. Revise the plan.
D. Evaluate the results
Answer: A. Determine goals
B. Implement recommended strategies
D. Evaluate the results

C. Revise the plan

9. A nurse is orienting to an emergency department. The nurse is asked to assist with suturing
of a laceration on a client’s hand. Which of the following is the best resource for this nurse?
A. The preceptor on the clinical unit
B. The provider suturing the client’s injury
C. The nursing supervisor
D. The information on the suture package
Answer: B. The provider suturing the client’s injury

10. 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. Assess the client for urinary retention.
B. Obtain a provider’s prescription for a blood alcohol level.
C. Tell the client that a catheter will be inserted.
D. Document the client’s refusal in the chart.
Answer: D. Document the client’s refusal in the chart.

11. While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that six of the 15 records lack documentation regarding advance directives.
Which of the following is the priority action for the nurse to take?
A. Ask nurses who are caring for clients without this information in the medical record to
obtain it.
B. Remind nurses to obtain this information during the admission process.
C. Meet with nursing staff to review the policy regarding advance directives.
D. Reinforce the potential consequences of not having this information on record to the
nursing staff.
Answer: C. Meet with nursing staff to review the policy regarding advance directives.

12. 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. Determine client care goals.
B. Review the client’s new laboratory values.
C. Complete required tasks.
D. Document assessment data.
Answer: A. Determine client care goals.

13. 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 gives prescribed opioids to a client who has a terminal illness and respirations of
8/min.
B. A nurse refuses to actively participate during an elective abortion procedure scheduled for
her client.
C. A nurse informs a confused client who wants to go home that he is going to stay at the
facility until he is better.
D. A nurse explains to a client’s family that a DNR includes withholding comfort measures.
Answer: D. A nurse explains to a client’s family that a DNR includes withholding comfort
measures.

14. A nurse is caring for a client who is unconscious and whose partner is his 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 this 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. “We’ll need to have the nursing supervisor review the client’s advance directives.”
B. “You should consider speaking with the facility’s ethics committee before making your
decision.”
C. “You have the right to make that decision, even if the partner is the client’s health care
proxy.”
D. “The client has designated his partner as health care proxy in his advance directives.”
Answer: D. “The client has designated his partner as health care proxy in his advance
directives.”

15. A parish nurse is making a referral to a community meal delivery program for a member
of the congregation. This is an example of which of the following functions of the parish
nurse?
A. Health educator
B. Liaison
C. Pastoral care provider
D. Personal health counselor
Answer: B. Liaison

16. 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. Laboratory results within the expected reference range
B. Level of consciousness
C. List of regularly prescribed medications
D. Date of last bowel movement
Answer: B. Level of consciousness

17. A charge nurse on a postpartum unit is teaching a client who gave birth 2 hr ago about the
facility’s protocols for preventing newborn abduction. Which of the following instructions
should the nurse include?
A. “Carry your baby snugly in your arms whenever you leave your room.”
B. “Make sure to leave your baby in the bassinet by your bed when you use the bathroom.”
C. “Keep your baby next to you in your bed if you think you might fall asleep.”
D. “Check the photo identification badge of staff members who care for you and your baby.”
Answer: D. “Check the photo identification badge of staff members who care for you and
your baby.”

18. 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 diabetes mellitus and a stage 2 pressure ulcer on his foot
B. A client who has a hip fracture and is in Buck’s traction
C. A client who has aspiration pneumonia and a respiratory rate 28/min ABC
D. A client who has a Clostridium difficile infection and needs a stool specimen collected

Answer: C. A client who has aspiration pneumonia and a respiratory rate 28/min ABC

19. A nurse should recognize that an incident report is required when
A. A visitor pinches his finger in the client’s bed frame.
B. A nurse gives a medication 30 min late.
C. A client throws a box of tissues at a nurse.
D. A client refuses to attend physical therapy.
Answer: A. A visitor pinches his finger in the client’s bed frame.

20. 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. Referring a client to social services for assistance with transportation
B. Providing the first oral feeding to a client following a stroke
C. Instructing a client who is obese about a low-fat diet
D. Changing the dressing on a postoperative wound
Answer: D. Changing the dressing on a postoperative wound

21. A nurse is 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. “Are you removing the client’s restraints every 4 hours?”
B. “Are you able to insert two fingers between the restraints and the client’s skin?”
C. “Did you tie the restraints using a double knot?”
D. “Did you secure the restraints to the side rails of the bed?”
Answer: B. “Are you able to insert two fingers between the restraints and the client’s skin?”

22. 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. Stridor
B. Asthma
C. Hyperventilation
D. Atelectasis
Answer: C. Hyperventilation

23. Which of the following observations requires a charge nurse to intervene and demonstrate
safe handling techniques?
A. A nurse uses goggles to perform tracheostomy suctioning.
B. A nurse places a mask on a client with tuberculosis before transport to the radiology
department.
C. A nurse cleans up a blood spill with a 1:10 bleach solution.
D. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a
specimen.
Answer: D. A nurse disconnects an indwelling urinary catheter from the drainage bag to
collect a specimen.
24. 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 maintain sterile technique? (SATA)
A. Opens the sterile pack by first unfolding the flap farthest from her body
B. Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field
C. Places sterile items within a 1.25-cm (0.5-inch) border around the edges of the sterile field
D. Removes the outside packaging of a sterile instrument before dropping it onto the sterile
field
E. Rests the cap of a solution container upside down on the sterile field
Answer: A. Opens the sterile pack by first unfolding the flap farthest from her body
B. Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field
D. Removes the outside packaging of a sterile instrument before dropping it onto the sterile
field

25. A nurse working on a medical-surgical unit is receiving shift report regarding four clients.
Which of the following client should the nurse see first?
A. A 75-year-old man who has pneumonia and has a O2 saturation of 92%
B. A 80-year-old woman who has a urinary tract infection and a temperature of 38.2° C
(100.8° F)
C. A 45-year-old man who has new onset of confusion 24 hr after a total hip arthroplasty
D. A 50-year-old woman reporting abdominal pain of 7 on a scale of 0 to 10

Answer: C. A 45-year-old man who has new onset of confusion 24 hr after a total hip
arthroplasty

26. 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

27. A client has a new permanent pacemaker inserted. Which of the following home care
instructions should the nurse include?
A. Swimming could cause the unit to have an electrical short.
B. The client should avoid using remote control devices to prevent dysrhythmias.
C. Regular programming evaluations can be conducted by telephone.
D. The client should avoid using a microwave oven to heat food.
Answer: C. Regular programming evaluations can be conducted by telephone.

28. According to HIPAA regulations, which of the following is a violation of client
confidentiality?
A. Reporting a client’s disposition to the referring provider
B. Informing housekeeping staff that the client is in the dialysis unit
C. Providing a copy of the record to the transporting paramedic
D. Telephoning the pharmacy with a prescription for the spouse to pick up
Answer: B. Informing housekeeping staff that the client is in the dialysis unit

29. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following to manage the
tracheostomy at home? (SATA)
A. Pipe cleaners
B. Cotton balls
C. Petroleum jelly

D. Oxygen tank
E. Obturator
Answer: A. Pipe cleaners
D. Oxygen tank
E. Obturator

30. 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. Provide a brief overview of the new scheduling system immediately before its
implementation.
B. Offer to reassign staff who do not support the change to another unit.
C. Identify nurses who accept the change to help influence other staff nurses.
D. Introduce the new scheduling system by describing how it will save the institution money.
Answer: A. Provide a brief overview of the new scheduling system immediately before its
implementation.
31. A nurse enters a client’s room and observes a fire in the trash can. Identify the sequence of
actions the nurse should take.
A. Remove the client from the area.
B. Activate the first alarm system.
C. Confine the fire by closing doors and windows.
D. Extinguish the fire if possible.
E. All of the above
Answer: E. All of the above
32. 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. Complete an incident report regarding the breach of the client’s confidentiality.
B. Report the possible violation of client confidentiality to the nurse manager.
C. Log out the computer so that the client’s son is unable to view his mother’s information.
D. Recommend the son meet with the provider to get information about his mother’s
condition.

Answer: C. Log out the computer so that the client’s son is unable to view his mother’s
information.

33. 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. Return unused supplies from the bedside to the unit’s supply stock.
B. Use clean gloves rather than sterile gloves for colostomy care.
C. Wait to dispose of sharps containers until they are completely full.
D. Store opened bottles of normal saline in a refrigerator for up to 48 hr.
Answer: B. Use clean gloves rather than sterile gloves for colostomy care.

34. Which of the following puts a hospital at the highest risk for infringement of client record
confidentiality?
A. Paper-based charts are stored at the nurses’’ station.
B. A provider and nurse access client information using once access code.
C. A nurse performs electronic documentation outside a client’s room.
D. A nurse clusters documentation of care for multiple clients.
Answer: B. A provider and nurse access client information using once access code.

35. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist
restraints to a client who is agitated and does not have a prescription for restraints. Which of
the following actions should the nurse take first?
A. Review the chart for non-restrain alternatives for agitation.
B. Speak with the AP about the incident.
C. Remove the restraints from the client’s wrists.
D. Inform the unit manager of the incident.
Answer: C. Remove the restraints from the client’s wrists.

36. A nurse is providing change-of-shift report for an oncoming nurse. Which of the
following information should the nurse include in the report?
A. “The client’s partner came to visit him 2 hours ago and smelled of alcohol.”
B. “The client is currently in the radiology department for a chest x-ray.”
C. “The client will need vital signs every 4 hours.”
D. “The client is the president of a local bank.”

Answer: B. “The client is currently in the radiology department for a chest x-ray.”

37. A client who has 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 okay. Soon everything will be just fine.” Which of the following is the nurse’s priority
action?
A. Ask the client if he has considered hurting himself.
B. Provide the client with information about Alcoholics Anonymous.
C. Encourage the client to participate in physical activities.
D. Reinforce the need to follow up with discharge referral.
Answer: A. Ask the client if he has considered hurting himself.

38. A charge nurse is addressing conflict between two nurses who are having a disagreement
at the nurses’ station. Which of the following strategies should the charge nurse use to assist
with negotiations? (SATA)
A. Continue negotiations until a resolution is made.
B. Have the nurses move the discussion to a private location.
C. Begin negotiations with minimal demands from each nurse.
D. Address the nurses using assertive communication techniques.
E. Use active listening when obtaining each nurse’s perception of the situation.
Answer: B. Have the nurses move the discussion to a private location.
D. Address the nurses using assertive communication techniques.
E. Use active listening when obtaining each nurse’s perception of the situation.

39. A nurse is providing care for four postoperative clients. The nurse should first assess the
client
A. Who is reporting nausea after the prescribed antiemetic was administered.
B. Whose pulse has been steadily increasing during the past shift.
C. Whose urine output has averaged 32 mL/hr for the past 24 hr.
D. Who is reporting a pain level of 8 on a scale of 0 to 10.
Answer: B. Whose pulse has been steadily increasing during the past shift.

40. A nurse finds a client sitting on the floor holding her right forearm. She tells the nurse that
she slipped and hit her arm. Which of the following actions should the nurse take first?

A. Submit an incident report.
B. Alert the client’s provider of the incident.
C. Reposition the client to prevent further injury.
D. Check the client for injuries.
Answer: D. Check the client for injuries.

41. A nurse in an acute care unit is assessing a group of clients. Which of the following
clients is the nurse’s priority?
A. A client who has pneumonia and has an oxygen saturation of 95%
B. A client who has atrial fibrillation and reports chest pain of 5 on a scale from 0 to 10
C. A client who has peripheral vascular disease and has +1 pedal pulses bilaterally
D. A client who has inflammatory bowel syndrome and reports two loose stools
Answer: B. A client who has atrial fibrillation and reports chest pain of 5 on a scale from 0 to
10

42. 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. Reposition the client for comfort.
B. Notify the nursing supervisor about the issue.
C. Contact the client’s physical therapist.
D. Apply a warm compress to the hip.
Answer: B. Notify the nursing supervisor about the issue.

43. 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 preschool child who was previously trained now requires diapers in the hospital.
C. A toddler cries whenever his parent enters the hospital room.
D. An adolescent admitted to the emergency department won’t speak to his parents.
Answer: C. A toddler cries whenever his parent enters the hospital room.

44. 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 client is covered with a woolen blanket.
B. The oxygen machine has a grounded plug.
C. The family keeps a spare oxygen tank in the room.
D. The windows of the client’s room are open.
Answer: A. The client is covered with a woolen blanket.

45. 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. Reddened area on the coccyx
B. Most recent blood glucose reading
C. Glasgow Coma Scale score
D. Laboratory tests scheduled for next shift
Answer: C. Glasgow Coma Scale score

46. A nurse in the emergency department is caring for a group of four clients. Which of the
following clients should the nurse recommend for transfer to the ICU?
A. A client who has chronic atrial fibrillation and a digoxin level of 0.3 ng/mL
B. A client who has bleeding esophageal varices and a blood pressure of 90/50 mm Hg
C. A client who has a head injury and Glasgow Coma Scale score of 10
D. A client who has chronic kidney disease and a creatinine level of 15 mg/dL
Answer: C. A client who has a head injury and Glasgow Coma Scale score of 10
47. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t
get better, I’m going to quit.” Which of the following responses by the unit manager is
appropriate?
A. “Just stick with it a little longer. Things will get better soon.”
B. “So you are upset about all the changes on the unit?”
C. “You should file a written complaint with hospital administration.”
D. “I think you have a right to be upset. I am tired of the changes, too.”
Answer: B. “So you are upset about all the changes on the unit?”

48. 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 assistive personnel?

A. Recording the client’s vital signs
B. Determining the client’s pain level
C. Checking the pulses of the client’s right foot
D. Turning the client
Answer: A. Recording the client’s vital signs

49. 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. Monitoring a client with a fluid restriction
D. Obtaining a stool sample from a client with renal failure
Answer: D. Obtaining a stool sample from a client with renal failure

50. A nurse is providing teaching to a client who has a new diagnosis of diabetes mellitus.
The client expresses concern about the cost of blood glucose monitoring supplies. Which of
the following referrals should the nurse make to address the client’s concern?
A. Case manager
B. Dietitian
C. Chaplain
D. House supervisor
Answer: A. Case manager

51. A nurse manager is providing orientation to a group of newly licensed nurses. The nurse
manager should communicate that which of the following actions is the responsibility of the
nurse when responding to a disaster?
A. Assume leadership for directing the emergency plan.
B. Use the chain-of-command for communication.
C. Act as a spokesperson between the facility and the community.
D. Coordinate the activities of emergency medical services.
Answer: A. Assume leadership for directing the emergency plan.

52. 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. A blood culture was obtained after antibiotic therapy had been initiated.
B. The route of antibiotic therapy on the care pathway was changed from IV to PO.
C. An allergy to penicillin required an alternative antibiotic to be prescribed.
D. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.
Answer: A. A blood culture was obtained after antibiotic therapy had been initiated.

53. A nurse is working on a quality improvement team that is assessing an increase in client
falls at a facility. After problem identification, which of the following actions should the
nurse plan to take first as part of the quality improvement process?
A. Review current literature regarding client falls.
B. Identify clients who are at risk for falls.
C. Notify staff of the increased fall rate.
D. Implement a fall prevention plan.
Answer: B. Identify clients who are at risk for falls.

54. To receive a conflict between staff members regarding potential changes in policy, a nurse
manager decides to implement the changes she prefers regardless of the feelings of those who
oppose those changes. Which of the following conflict-resolution strategies is the nurse
manager using?
A. Compromising
B. Cooperating
C. Competing
D. Collaborating
Answer: C. Competing

55. 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. Ask other staff members to take over some of his tasks.
B. Advise him to complete less time-consuming tasks first.
C. Recommend that he take time to plan at the beginning of his shift.

D. Offer to provide care for his clients while he takes a break.
Answer: C. Recommend that he take time to plan at the beginning of his shift.

56. Client satisfaction surveys from a surgical unit indicate that pain is not being adequately
relieved during the first 12 hr postoperatively. The unit manager decides to identify
postoperative 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. Pain assessment policy
C. Postoperative care policy
D. Retrospective chart audit
Answer: C. Postoperative care policy
57. 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 suggests counseling for the client’s body image issues.
B. The nurse investigates potential resources to help the client purchase a wig.
C. The nurse informs the next shift nurse regarding the mother’s concerns.
D. The nurse explains to the mother that most clients with cancer lose their hair.
Answer: B. The nurse investigates potential resources to help the client purchase a wig.

58. 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 has a 4-inch laceration on the forearm
B. A client who has an open fracture of the femur
C. A client who reports substernal chest pain radiating to the neck
D. A client who has a penetrating head injury and fixed and dilated pupils
Answer: C. A client who reports substernal chest pain radiating to the neck

59. 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. Request the consultation after several wound care treatments are tried.
B. Arrange the consultation for a time when the nurse caring for the client is able to be
present for the consultation.
C. Provide the consultant with subjective opinions and beliefs about the client’s wound care.
D. Arrange for the wound care nurse specialist to see the client daily to provide the
recommended treatment.
Answer: B. Arrange the consultation for a time when the nurse caring for the client is able to
be present for the consultation.

60. Which of the following items must be discarded in a biohazard waste receptacle?
A. A bedsheet from a client with bacterial pneumonia
B. An empty IV bag removed from a client who has HIV
C. A urinary catheter drainage bag from a client who is postoperative
D. A peripheral pad from a client who is 24-hr post-vaginal delivery
Answer: D. A peripheral pad from a client who is 24-hr post-vaginal delivery

61. A client is admitted with tuberculosis and placed in a negative pressure room. Which of
the following nursing actions is appropriate?
A. Notify the local health department of the admission.
B. Ensure that admitting staff undergo PPD skin tests.
C. Place a sign on the client’s door with the diagnosis.
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.
62. A nurse is preparing to transcribe a client’s medication prescription in the medical record.
Which of the following should the nurse recognize as containing the essential components of
a medication order?
A. Haloperidol 1 mg by mouth
B. Multivitamin every morning by mouth
C. Aspirin 650 mg by mouth every 4 hr
D. NPH insulin 10 units before meals and at bedtime
Answer: C. Aspirin 650 mg by mouth every 4 hr

63. A nurse is caring for a client who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted in regard to this client’s care? (SATA)
A. Case manager
B. Mental health counselor
C. Physical therapist
D. Nutritional therapist
E. Occupational therapist
Answer: A. Case manager
B. Mental health counselor
D. Nutritional therapist

64. 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. “An incident report should be completed if a client receives a stick from her own used
needle.”
B. “I should stop the bleeding as soon as possible following a needlestick injury.”
C. “Prophylactic treatment should be initiated after a needlestick during preparation of an
injection.”
D. “The needle should be recapped to prevent injury during transport to the biohazard
container.”
Answer: C. “Prophylactic treatment should be initiated after a needlestick during preparation
of an injection.”

65. 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. Threatening to apply wrist restraints to control a client who is agitated
C. Inserting a feeding tube against the wishes of a client who refuses to eat
D. Telling a client who refused his oral medication that he will be given an injection
Answer: C. Inserting a feeding tube against the wishes of a client who refuses to eat

66. A charge nurse notices that two staff nurses are not taking meal breaks during their
regular 8-hr shifts. Which of the following actions should the nurse take first?
A. Provide coverage for the nurses’ breaks.

B. Discuss time management strategies with the nurses.
C. Determine the reasons the nurses are not taking scheduled breaks.
D. Review facility policies for taking scheduled breaks.
Answer: B. Discuss time management strategies with the nurses.

67. A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
A. Determine adequacy of ventilator settings.
B. Plan break times for assistive personnel.
C. Administer a nasogastric tube feeding.
B. Pick up the meal trays after lunch.
Answer: C. Administer a nasogastric tube feeding.

68. 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 telehealth?
A. Assessing client needs
B. Providing medication reconciliation
C. Developing client treatment protocols
D. Establishing communication between providers
Answer: D. Establishing communication between providers

69. 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. Remove the nurse from the unit.
B. Have a blood alcohol level drawn from the nurse.
C. Report the situation to the director of nursing.
D. Document a factual description of the situation.
Answer: A. Remove the nurse from the unit.

70. A case manager working in a rehabilitation unit is discharging to home a client who has a
spinal cord injury at vertebral 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. Provide educational handouts related to care requirements.
C. Identify the client’s ability to perform activities of daily living.
D. Recommend community resources available to assist with client care.
Answer: C. Identify the client’s ability to perform activities of daily living.

1. 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 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: C

2. 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

3. 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 min late
Answer: D

4. Client satisfaction surveys from a surgical unit indicate that pain is not being adequately
relieved during the first 12 hr post operatively. The unit manager decides to identify
postoperative 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

5. A nurse is 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 of the rails of the bed?”
B. “Are you able to slip two fingers between the restraints 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

6. 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 are tried.
D. Arrange for the wound care nurse specialist to see the client daily to provide the
recommendation treatment.
Answer: C

7. A client is admitted with tuberculosis and placed in a negative pressure room. Which of the
following nursing 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: A

8. A nurse is caring for a client who is unconscious and whose partner is his 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 this 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 that 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 advanced directives.”
D. “We’ll need to have the nursing supervisor review the client’s advanced directives.”
Answer: C

9. 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. Laboratory tests scheduled for next shift
D. Reddened area on the coccyx
Answer: A
10. A nurse is assigned the four following client’s for the current shifts. Which of the
following clients should the nurse assets first?
A. A client who has a hip fracture and is in buck’s traction
B. A client who bas aspiration pneumonia and a respiratory rate of 28/min
C. A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot
D. A client who has a clostridium difficile infection and needs a stool specimen collected
Answer: B

11. 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 issue
B. Contact the client’s physical therapist
C. Apply a warm compress to the hip
D. Reposition the client for comfort
Answer: A
12. 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 client’s 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

13. 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 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
14. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t
get better, I’m going to quit.” Which of the following responses by the unit manager is
appropriate?
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 changes too
C. just stick with it a little longer. Things will get better soon
D. you should file a written complaint with hospital administration
Answer: A

15. According to HIPPA regulation, 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
16. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with
sterile procedure.
Which of the following actions indicates the nurse is maintaining sterile techniques (select all
that apply)
A. opens the sterile pack by first unfolding the flap farthest from her body
B. rests the cap of solution container upside down on the sterile field
C. holds a bottle of sterile solution 15cm (6 inches) above the sterile field
D. Places sterile items within a 1.25cm (.5inch) border around the edges of the sterile field.
Answer: A, C

17. A nurse is providing care for four postoperative clients. The nurse should assess the client
A. whose pulse has been steadily increasing during the past shift
B. who is reporting pain level of 8 on a scale of 0-10
C. whose urine output has averaged 32ml/hr for the past 24hrs
D. Who is reporting nausea after the prescribed antiemetic was administered
Answer: A
18. A nurse is preparing to transcribe a client’s medication prescription in the medical record.
Which of the following should the nurse recognize as containing the essential components o f
a medication order
A. NPH insulin 10 units before meals and at bedtime
B. Haloperidol(Haldol)1mgbymouth
C. Multivitamin every morning by mouth
D. Aspirin 650mg by mouth every 4 hours
Answer: D

19. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed
nurse is having trouble focusing and has difficulty completing care for his assigned clients.
Which of the following interventions is appropriate?
A. Recommend that he take time to plan at the beginning of his shift
B. Advise him to complete less time consuming tasks first
C. Ask other staff members to take over some of his tasks
D. Offer to provide care for his clients while he takes a break
Answer: A

20. A nurse is 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 clients clothing
B. Irrigate the exposed area with water
C. Report the incident to OSHA
D. Don personal protective equipment
Answer: D

21. 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 terminal illness and respirations of
8/m
C. A nurse explains to a client’s family that DNR orders 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

22. A nurse in an ambulatory care setting is orienting a newly licensed nurse who is preparing
to return a call to a client. The nurse should explain that which of the following is an
objective of telehealth
A. Assessing client needs
B. Providing medication reconciliation

C. Establishing communication between providers
D. Developing client treatment protocols
Answer: A

23. 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 nurse’s station
D. A nurse performs electronic documentation outside a client’s room
Answer: B

24. 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 tuberculosis before transport to the radiology
department
Answer: C

25. 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 parent enters the hospital room
C. An adolescent admitted to the emergency department won’t speak to his parents
D. A preschool child who previously toilet trained now requires diapers in the hospital
Answer: A

26. 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

27. 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 and dilated pupils
Answer: D
29. A nurse manager over hears 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 client information is confidential
D. Fill out an incident report regarding the situation.
Answer: C

30. A client who has 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 okay. Soon everything will be just fine.” Which of the following is the nurse’s priority
action?
A. Ask the client if he has considered hurting himself.
B. Provide the client with information about Alcoholics Anonymous
C. Encourage the client to participate in physical activities
D. Reinforce the need to follow up with discharge referral.
Answer: A

31. 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

32. 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 form the unit.
Answer: C

33. A nurse observes a paper bag at the bedside of a client. The finding suggests that a client
is receiving treatment for which of the following respiratory disorders?
A. Asthma
B. Hyperventilation
C. Stridor
D. Atelectasis
Answer: A

34. 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. Laboratory results within the expected reference range
B. List of regularly prescribed medications
C. Date of last bowel movement
D. Level of consciousness
Answer: D

35. 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 laboratory values.

B. Document assessment data.
C. Complete required tasks
D. Determine client care goals.
Answer: D

36. 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 a N95 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

38. 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 to a client to social services for assistance with transportation
C. Instructing a client who is obese with a low-fat diet
D. Providing the first oral feeding to a client following a stroke
Answer: A

39. A case manager working in a rehabilitation unit is discharging to home a client who has a
spinal cord injury at vertebral 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

40. A nurse is preparing to complete morning assessments on several assigned clients. Which
of the following clients should the nurse plan to assess first? REPEAT
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 postoperative and whose dressing has serosanguinous drainage
Answer: A

41. 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

42. A 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 REPEAT
A. Recording of daily intake and output
B. Assistance with meals
C. A complete bed bath
D. Frequent dressing changes.
Answer: D

44. 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 haemodialysis
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

45. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist
restraints to a client who is agitated and does not have a prescription for restraints. Which of
the following actions should the nurse take first?
A. Inform the unit manager of the incident
B. 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

46. 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 REPEAT
B. Tell the client that a catheter will be inserted
C. Obtain a provider’s prescription for the blood alcohol level
D. Assess the client for urinary retention
Answer: A

47. Nurses on an in-patient care unit are working to help reduce unit costs. Which of the
following is appropriate to include in the cost-containment plan? REPEAT
A. Use clean gloves rather than sterile gloves for colostomy care
B. Wait to dispose of sharps container 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

48. 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? REPEAT
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 food
Answer: B

49. To resolve the 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

50. 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 postoperative following a Caesarean section and has a
PCA pump
C. A multigravida client who has preeclampsia and is receiving mistoprostol (Cytotec) for
induction of labor
D. A client who is at 32 weeks of gestation and has a premature rupture of membranes
Answer: B

51. A nurse working on a medical-surgical unit is managing care of four 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 level of 4.2 g/dL
B. A client who has Type 1 diabetes 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 (On heparin: 45-80 sec)
Answer: D

52. 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 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

53. 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 (AP/CNA)
B. Providing postmortem care for a client who has just died (AP/CNA)
C. Accompanying a client who just had a wound debridement to physical therapy (AP/CNA)
D. Reinforcing dietary teaching with a client who has heart disease
Answer: D
54. 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? REPEAT
A. Recommend the son meet with the provider to get information about his mother’s
condition
B. Complete an incident report regarding the breach of the client’s confidentiality
C. Log out the computer so that the client’s son is unable to view his mother’s information
D. Report the possible violation of client confidentiality to the nurse manager
Answer: C

55. 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 woollen blanket
Answer: D

56. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the
following instructions should the nurse include? REPEAT
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

57. 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? REPEAT
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

58. A client has a new permanent pacemaker inserted. Which of the following home care
instructions should the nurse include? REPEAT
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. Swimming could cause the unit to have an electrical short
Answer: B

59. While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that six of the 15 records lack documentation regarding advance directives.
Which of the following is the priority action for the nurse to take?
A. Reinforce the potential consequences of not having this information on record to the
nursing staff
B. Ask nurses who are caring for clients without this information in the medical record to
obtain it.
C. Meet with the nursing staff to review the policy regarding advance directives
D. Remind nurses to obtain this information during the admission process

Answer: C

60. 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. White blood cell count 9,000/mm^3
C. Report of dyspnea on exertion
D. Bilateral crackles on auscultation of lungs
Answer: D

61. A charge nurse notices that two staff nurses are not taking meal breaks during their
regular 8-hr shifts. Which of the following actions should the nurse take first?
A. Providing coverage for the nurses’ breaks
B. Determining the reasons the nurses are not taking scheduled breaks
C. Discussing time management strategies with the nurses
D. Review facility policies for taking scheduled breaks
Answer: D

62. 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, D, E

63. 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 interpret to obtain informed consent from a client who is deaf.”
D. “The nurse can answer any questions the client has about the procedure”

Answer: B

64. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize
that which of the following clients is the highest priority?
A. A client who is newly diagnosed with pancreatic cancer and scheduled to begin IV
chemotherapy
B. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
C. A client who is postoperative following a laminectomy 12 hours ago and is unable to void
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38 C (101 F)
Answer: B

65. A client is scheduled for a tubal ligation procedure starts to cry as she is wheeled into the
surgical units. 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.” REPEAT
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

66. 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 area
Answer: C

67. A nurse is working on a quality improvement team that is assessing an increase in client
falls at the facility. After problem identification, which of the following actions should the
nurse plan to take first as part of the quality improvement process? REPEAT
A. Review current literature regarding client falls
B. Implement a fall prevention plan
C. Notify staff of the increased fall rate

D. Identify clients who are at risk for falls
Answer: D

68. A nurse is evaluating a newly licensed nurse who is administering a vitamin K.
(Aquamephyton) injection to a newborn. Which of the following actions by the newly
licensed nurse indicates understanding of the teaching? (Select all that apply.) REPEAT
A. Selects the dorsogluteal site to administer the injections
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 (90 degree)
Answer: B, C, D
69. A nurse enters a client’s room and observes a fire in the trash can. Identify the sequence of
actions the nurse should take. (Move all the actions into the box on the right, placing them in
the selected order of performance.)
A. Activate the fire alarm system
B. Confine the fire by closing doors and windows
C. Extinguish the fire if possible
D. Remove the client from the area
Answer:

70. 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 (REPEAT)
D. Threatening to apply wrist restraints to control a client who is agitated
Answer: C

ATI LEADERSHIP
VERSION 9

The home health nurse is visiting the home of a client that has been diagnosed with a brain
tumor. The family states that the client has been having more frequent seizures. What nursing
care should be provided? (Found in Adult Medical Surgical Review Module)
Answer: • Maintain airway (monitor oxygen levels, administer oxygen as needed, monitor
lung sounds).
• Monitor neurological status — in particular, assessing for changes in level of consciousness,
neurological deficits, and occurrence of seizures.
• Maintain client safety. (Assist with transfers and ambulation, provide assistive devices as
needed.)
• Implement seizure precautions.
• Administer medications as prescribed.
• The nurse is collaborating with the health care team to create a plan of care for a client
following a stroke. Explain the nurse’s role in continuity of care. The nurse role in continuity
care is a coordinator, documentation, communication, consultations, referrals, transfer and
discharge planning.

An elderly client is being discharged from the hospital to home following a long
hospitalization. What are some community resources that the nurse should initiate referrals
for this client?
Answer: • Specialized equipment (cane, walker, wheelchair, grab bars in bathroom)
• Specialized therapists (physical, occupational, speech)
• Care providers (home health nurse, hospice nurse, home health aide

What behaviors would indicate to the charge nurse that one of the nurses could be
experiencing countertransference? (Found in the Mental Health Review Module)
Answer: • Nurse overly identifies with client
• Nurse competes with client
• Nurse argues with client

List the six (6) Quality and Safety Education for Nurses (QSEN) competencies and explain
their importance.
Answer: 1. PATIENT-CENTERED CARE: The provision of caring and compassionate,
culturally sensitive care that addresses clients’ physiological, psychological, sociological,
spiritual, and cultural needs, preferences, and values.
2. TEAMWORK AND COLLABORATION: The delivery of client care in partnership with
multidisciplinary members of the health care team to achieve continuity of care and positive
client outcomes.
3. EVIDENCE-BASED PRACTICE: The use of current knowledge from research and other
credible sources on which to base clinical judgment and client care.
4. QUALITY IMPROVEMENT: Care-related and organizational processes that involve the
development and implementation of a plan to improve health care services and better meet
clients’ needs.
5. SAFETY: The minimization of risk factors that could cause injury or harm while
promoting quality care and maintaining a secure environment for clients, self, and others.
6. INFORMATICS: The use of information technology as a communication and informationgathering tool that supports clinical decision-making and scientifically-based nursing practice

A client's wife calls the charge nurse to the room and states she is very angry with the nursing
staff because her husband is "not receiving adequate nursing care". What problem solving
strategies should the charge nurse use in this situation?
Answer: • Conflict Management Strategies: Identify the problem – State it in objective
terms, minimizing emotional overlay.
• Discuss possible solutions – Brainstorming solutions as a group may stimulate new
solutions to old problems. Encourage individuals to "think outside the box. "Analyze
identified solutions – The potential pros and cons of each possible solution should be
discussed in an attempt to narrow down the number of viable solutions. Select a solution –
Based on this analysis, select a solution for implementation. Implement the selected solution
– A procedure and timeline for implementation should accompany the implementation of the
selected solution. Evaluate the solution's ability to resolve the original problem – The
outcomes surrounding the new solution should be evaluated according to the predetermined
timeline. The solution should be given adequate time to become established as a new routine
before it is evaluated. If the solution is deemed unsuccessful, the problem-solving process
will need to be reinstituted and the problem discussed again.

Upon admission to a healthcare facility, what are the nurse’s responsibilities regarding a
living will?
Answer: • Providing written information regarding advance directives
• Documenting the client’s advance directives status
• Ensuring that advance directives are current and reflective of the client’s current decisions
• Recognizing that the client’s choice takes priority when there is a conflict between the client
and family, or between the client and the provider
• Informing all members of the health care team of the client’s advance directive

The charge nurse takes a telephone order for morphine 50 mg IVP every 3 hours. After
hanging up the phone, the nurse feels this order is not safe. List three (3) strategies to prevent
errors of miscommunication when receiving telephone orders.
Answer: • Use strategies to prevent errors when taking a medical prescription that is given
verbally or over the phone by the provider.
• Repeat back the prescription given, making sure to include the medication name (spell if
necessary), dosage, time, and route.
• Question any prescription that seems contraindicated due to a previous or concurrent
prescription or client condition.

An ethical dilemma regarding sustaining life is being examined. What would be some
appropriate resources for the nurse to use to help review and address ethical dilemmas?
Answer: • The American Nurses Association Code of Ethics for Nurses
• The Uniform Determination of Death Act (UDDA) can be used to assist with end‑of‑life
and organ donor issues.
• International Council of Nurses’ Code of Ethics for Nurses
• The Code of Ethics for Licensed Practical/Vocational Nurses

A nurse is caring for a client with acute cystitis that has been prescribed nitrofurantoin
(Macrobid). What client education should be provided to the client regarding this
medication? (Review the Pharmacology Review Module)
Answer: • Inform clients that nitrofurantoin turns urine rust‑yellow to brown and can stain
teeth.
• Encourage clients to take it with food if adverse GI effects occur.

• Instruct clients to complete the entire course of therapy, even if manifestations resolve
sooner.
Recommend that clients avoid crushing, chewing, or opening capsules because of the
possibility of tooth staining.
• Instruct clients to avoid nitrofurantoin while pregnant (can cause birth defects).

The nurse knows the following detail is true regarding a client's care when exposed to
botulism:
Answer: 1. Vaccination administration markedly improves symptoms
2. Airborne isolation is instituted
3. Supportive care with mechanical ventilation is common
4. Antiviral therapy is administered

A nurse is working on a maternal newborn unit. What security measures should the nurse
ensure are in place to prevent abduction? (Found in the Maternal Newborn Review Module)
Answer: • The newborn, mother, and mother’s partner are identified by plastic identification
wristbands with permanent locks that must be cut to be removed. Identification bands should
include the newborn’s name, sex, date, and time of birth, and mother’s health record number.
The newborn should have one band placed on the ankle and one on the wrist. In addition, the
newborn’s footprints and mother’s thumb prints are taken. The above information is also
included with the footprint sheet.
• Each time the newborn is given to the parents, the identification band should be verified
against the mother’s identification band.
• All facility staff who assist in caring for the newborn are required to wear photo
identification badges
• The newborn is not to be given to anyone who does not have a photo identification badge
that distinguishes that person as a staff member of the facility maternal‑newborn unit.
• Many facilities have locked maternal‑newborn units that require staff to permit entrance or
exit. Some facilities have a sensor device on the ID band or umbilical cord clamp that sounds
an alarm if the newborn is removed from the facility.

A community health nurse is teaching a group of clients who live in a rural area about
prevention of the West Nile virus. What teaching points can the nurse discuss with the group
of clients about this disease process? (Review the Community Health Review Module)

Answer: • Eliminate sources of standing water (empty water from flower pots, pet food and
water dishes, birdbaths)

Financial barriers to healthcare are a huge concern to people around the world. Describe three
(3) organizations who provide financial assistance to healthcare.
Answer: • World Health Organization (WHO)
• Federal health agencies
• Private health
• The community health nurse is speaking to a men's civic group about health promotion for
men. The question is posed regarding how and when to properly perform testicular selfexamination (TSE). What would be the priority information to provide to the group? (Review
the Community Health Review Module)
• Do a self-exam in the shower once a month with warm water

A nurse is preparing a client for discharge. Identify three (3) vital teaching points to discuss
with the client prior to discharge.
Answer: • Review signs and symptoms of potential complications and when to contact the
provider.
• Provide names and numbers of community recourses
• Directions and information on medications

A nurse is planning care for a client who practices Mormonism. What are spiritual rituals and
observances a culturally competent nurse can be aware of? (Review the Fundamentals
Review Module)
Answer: • BIRTH RITUALS AND HEALTH CARE DECISIONS: Children are baptized at
age 8 by immersion.
• DIETARY RITUALS: Clients avoid alcohol, tobacco, and caffeine.
• DEATH RITUALS: Last rites include wearing temple clothes for burial and Burial is
preferred.

The nurse identifies health care beliefs can originate from different cultural practices. Match
the client's statement regarding the development of diabetes with the cultural belief.
Answer: Beliefs to Match to description:

• Biomedical beliefs: "I developed diabetes because my pancreas does not excrete insulin,
this is hereditary."
• Naturalistic beliefs: "My body was HOT and therefore developed diabetes, I will need to eat
yogurt and milk to help control the diabetes."
• Magico-religious beliefs: "I will pray that my blood sugars will be better controlled. God
can heal all."
Risk for violent behavior can be identified using the epidemiological triangle’s 3 components:
Host, Agent and Environment. Provide an example of each factor that can influence violent
behavior. (Found in the Community Health Review Module)
Answer: • HOST: age, gender, genetics, ethnicity, immune status, physiological state,
occupation
• AGENT: chemical (drugs, toxins), physical (noise, temperature), infectious agents (viruses,
bacteria)
• ENVIRONMENT: geography, water/ food supply, access to health care, high risk working
conditions, poverty

A nurse is caring for a client with a minor head injury. What are manifestations of increasing
intracranial pressure that should be reported to the provider? (Review the Adult Med Surgical
Review Module)
Answer: • Severe headache, nausea, vomiting
• Deteriorating level of consciousness, restlessness, irritability
• Dilated or pinpoint nonreactive pupils
• Alteration in breathing pattern (Cheyne‑Stokes respirations, central neurogenic
hyperventilation, apnea)
• Deterioration in motor function, abnormal posturing (decerebrate, decorticate, flaccidity)
• Cushing’s triad is a late finding characterized by severe hypertension with a widening pulse
pressure (systolic – diastolic) and bradycardia.
• Seizures

ATI Leadership
VERSION 10

1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of change
in wound care procedure. Which of the following findings indicate wound healing?
Answer: A. Deep red color on the center of the clients wound.

2. A nurse received a change-of-shift report at 0700 on four clients. Which of the following
actions should the nurse perform first?
Answer: A. Obtain a breakfast tray for a client who received a morning dose of insulin
aspart.

3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the
following clients should the nurse assign to the newly licensed nurse?
Answer: A. A client who has multiple sclerosis and ataxia.

4. A nurse is providing teaching to a client about advance directives. Which of the following
statements by the client indicates an understanding of the teaching?
Answer: A. “My durable power of attorney for health care is part of my advance directives.

5. A nurse is chairing a committee about preventing infant abduction in a newborn birth care
center. Which of the following quality control tasks should the nurse assigned to be
completed first?
Answer: A. Identify the industry standards for infant safety.

6. A nurse notes that a client is eating about half of the food on his plate and coughs
frequently during meals. The nurse plans to perform dysphagia screening to determine the
client’s need for referral to which of the following providers?
Answer: A. Speech therapist

7. A home health nurse is assessing the home environment during an initial visit to a client
who has a history of falls. Which of the following findings should the nurse identify as
increasing the clients risk for fall. SATA
Answer: A. A wheeled office chair at the client’s computer desk.
B. A throw rug covering some cracked vinyl flooring in the kitchen.
C. A folding chair without arm rests.

8. A nurse manager is planning to assign care for four clients on a medical-surgical unit.
Which of the following clients should the nurse assign to the licensed practical nurse?
Answer: A. A middle adult client who had a below-the-knee amputation and requires a
dressing change.

9. While auditing the medical records of clients currently in the oncology unit, the nurse
manager finds that six of the 15 records lack documentation regarding advanced directives.
Which of the following is the priority action for the nurse to take?
Answer: A. Ask the nurses who are caring for clients without this medical information to
obtain it.

10. A nurse is caring for a group of clients. Which of the following clients should the nurse
see first?
Answer: A. A client who has diabetes mellitus and is diaphoretic.

11. A nurse is receiving change-of-shift report for four clients. Which of the four clients
should the nurse care for first?
Answer: A. A client who is 4 hr. postoperative following a hernia repair and has pitting
edema of the right leg.

12. A nurse manager discovers there is a conflict between nurses working the day shift and
nurses working the night shift. Which of the following actions should the nurse manager take
first?
Answer: A. Gather information regarding the situation.

13. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid
chemical in an industrial setting. Which of the following actions should the nurse take first?
Answer: A. Don personal protective equipment.

14. A newly licensed nurse realized that she administered metoprolol 25 mg PO to the wrong
client. Which of the following actions should the nurse perform first?
Answer: A. Measure the client’s vital signs.

15. A nurse is assessing a client who has meningitis. Which of the following findings should
the nurse report to the provider immediately?
Answer: A. Decreased level of consciousness

16. A client who is febrile is admitted to the hospital for treatment of pneumonia. In
accordance with the care pathway, antibiotic therapy is prescribed. Which of the following
situations requires the nurse to complete a variance report with regard to the care pathway?
Answer: A. A blood culture was obtained after antibiotic therapy had been initiated.

17. A nurse manager is making staffing assignments for the maternal newborn unit. Which of
the following clients should the nurse manager assign to a float nurse from the medicalsurgical unit?
Answer: A. A client who is 2 days postoperative following a cesarean birth and is having
difficulty ambulating.

18. A nurse is coordinating an interprofessional team to review proposes standards to reduce
the transmission of methicillin-resistant Staphylococcus aureas (MRSA). Which of the
following members of the interprofessional team should the nurse consult?
Answer: A. Infection control nurse.

19. A nurse is caring for a client who has uterine prolapse. The provider has recommended to
total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option.
Which of the following is an appropriate action for the nurse to take?
Answer: A. Discuss with the client her concerns with the procedure.

20. A nurse in an emergency department is assessing a client who is unconscious following a
motor-vehicle crash. The client requires immediate surgery. Which of the following actions
should the nurse take?
Answer: A. Transport the client to the operating room without verifying informed consent.

21. A nurse is planning to delegate client care assignments. Which of the following tasks
should the nurse plan to delegate to an assistive personnel?
Answer: A. Performing postmortem care prior to transferring the client to the morgue.

22. A nurse working on a quality improvement team that is assessing an increase in client
falls at the facility. After problem identification, which of the following actions should the
nurse plan to take first as part of the quality improvement process?
Answer: A. Identify clients who are at risk for falls.

23. A nurse is completing a performance evaluation for an assistive personnel (AP). Which of
the following actions by the AP requires interventions by the nurse?
Answer: A. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium
difficile.

24. A charge nurse that staff nurses are having difficulty using new IV infusion pumps for
medication administration. Which of the following is priority action by the charge nurse?
Answer: A. Assess the staff nurses’ knowledge deficits.

25. A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which
of the following tasks should the nurse assign to the AP?
Answer: A. Collect a urine specimen from a newly admitted client.

26. A nurse is assisting with triage during a mass casualty event. A nurse applies a red tag to a
client. Which of the following actions should the nurse take?
Answer: A. Provide treatment for life-threatening injuries.
27. A home health nurse is performing a safety assessment of a client’s home. Which of the
following findings should the nurse identify as a safety hazard?
Answer: A. The client’s bedside lamp is plugged in using an extension cord with two prongs.

28. A charge nurse is observing a newly licensed nurse provide care for a client who has a
Clostridium difficile infection. Which of the following actions by the newly licensed nurse
indicates an understanding of proper infection control procedure?
Answer: A. Wears a gown when caring for the client.

29. A nurse is preparing to discharge planning for a client who has a newly placed
tracheostomy tube. The nurse should assess the client’s need for which of the following
supplies to manage the tracheostomy at home? (SATA)

Answer: A. Pipe cleaners
B. Obturator
C. Oxygen tank

30. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the
following clients can give informed consent?
Answer: A. An adolescent client who is legally emancipated.

31. A nurse is discussing the safe keeping of valuables with a client who is scheduled for
surgery. Which of the following client statements indicates the need for further teaching?
Answer: A. “I can wear my ankle bracelet since I am just having a local anesthetic.”

32. 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?
Answer: A. Arrange the consultation for a time when the nurse caring for the client is able to
be present for the consultation.

33. A nurse is observing an assistive personnel (AP) administer a 0.9% sodium chloride
enema to an adult client. For which of the following actions by the AP should the nurse
intervene?
Answer: A. Administers the solution at room temperature.

34. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
Answer: A. “I should encrypt personal health information when sending emails.”

35. A nurse is participating on a committee that is considering the creation of a policy that
will allow nurses to remove chest tubes. Which of the following is an appropriate resource for
the nurse to consult when planning for this policy?
Answer: A. ANA Standards of Practice

36. A charge nurse observes a licensed practical nurse (LPN) tell the client that she will return
with a medication to help relieve the client’s nausea. The LPN does not return with the

medication. The charge nurse should reinforce which of the following ethical principles with
the LPN
Answer: A. Fidelity

37. A nurse administrator is using benchmarking as control criteria while reviewing current
policies and procedures. Which of the following actions should the nurse take?
Answer: A. Use root cause analysis to identify gaps in meeting standards.
38. A nurse enters the client’s room and identifies that the client is receiving too much IV
fluid because the IV pump is not working properly. Which of the following actions should the
nurse take first?
Answer: A. Auscultate the client’s lungs.

39. A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the
surgical suite. Which of the following nurse’s statements is a proper nurse’s response?
Answer: A. “It’s not too late to cancel the surgery if you want to.”

40. A facility infection control nurse is reviewing the reports of a group of clients. Which of
the following infections should the nurse report to the public health department?
Answer: A. Lyme disease.

41. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility.
Which of the following information should the nurse include in the change-of-shift report?
Answer: A. The time the client received his last dose of pain medication.
42. A nurse receives a new prescription over the telephone from a client’s provider. Which of
the following actions should the nurse take first?
Answer: A. Read back the prescription to the provider.

43. A charge nurse witnesses an assistive personnel (AP) failing to follow facility protocol
when discarding contaminated linens. Which of the following actions should the nurse take
first?
Answer: A. Discuss the issue with the A.P

44. A nurse is planning to care for a client who is disoriented and has a history of wandering.
Which of the following actions should the nurse include in the plan?
Answer: A. Provide distractions for the client during the day.

45. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the
following actions should the nurse take?
Answer: A. Report the infection to the local health department.

46. A nurse is teaching a class of newly licensed nurses about evidence-based practice. The
nurse should include which of the following as the first step in evidence-based practice?
Answer: A. Develop a clinical question.

47. A nurse assumes the leading role on the hazardous materials team immediately following
a chemical mass casualty incident in the community. As clients arrive at the designated triage
area outside the hospital, which of the following actions should the nurse take?
Answer: A. Remove contaminated clothing.

48. A case manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse
manager should identify that which of the following torts has occurred?
Answer: A. Libel

49. A nurse is preparing to complete morning assessments on several assigned clients. Which
of the following clients should the nurse assess first?
Answer: A. A client who has a nasogastric tube to intermittent suction and reports nausea.
50. A charge nurse overhears a staff nurse discussing a client’s diagnosis in the cafeteria.
Which of the following responses should the charge nurse make?
Answer: A. “Please stop discussing the client in a public area.”

51. A nurse preceptor is observing a newly hired nurse perform a sterile dressing change.
Which of the following actions should the nurse preceptor identify as maintaining sterile
technique?
Answer: A. Uses sterile forceps to pack sterile gauze into the wound.

52. A nurse working in a long-term care facility is assessing an older adult client who has
been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the
following actions should the nurse take?
Answer: A. Clean the equipment in the client’s room with bleach.

53. 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 the assigned clients.
Which of the following interventions is appropriate?
Answer: A. Recommend that he take time to plan at the beginning of his shift.

54. A nurse is planning discharge for a client who had a lung resection. The nurse initiates a
referral for a social worker. Which of the following assessment data supports the referral?
Answer: A. The client needs to arrange financial resources to purchase equipment.

55. A nurse initiates a referral to an occupational therapist for a client who has rheumatoid
arthritis. Which of the following assessment findings supports the need for a referral?
Answer: A. The client requires assistance with completing oral hygiene.

56. A nurse is caring for a client who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted in regards to this client’s care? SATA
Answer: A. Mental health counselor
B. Case manager
C. Nutritional therapist

57. A nurse is prioritizing care after receiving a change-of-shift report on four clients. Which
of the following clients should the nurse assess first?
Answer: A. A client who reports indigestion and jaw pain.

58. A nurse on an acute mental health unit is assessing four clients. Which of the following
clients is highest priority?
Answer: A. A client who has bipolar disorder and displays constant pacing.

59. A nurse is planning care for a group of clients. Which of the following actions should the
nurse take first?
Answer: A. Check a client who has a leg cast and reports a new onset of pain.

60. A nurse on a medical-surgical unit is caring for a client who asks about advance directives
and states that he wants to appoint a healthcare proxy. Which of the following responses
should the nurse make?
Answer: A. “A healthcare proxy can make decisions for you when you are unable to do so.”

61. A nurse in a rehabilitation facility is administering medications to a client who was
admitted earlier that day. The client refuses two medications stating, “I’ve never taken these
before.” Which of the following actions should the nurse take first?
Answer: A. Compare the client’s medication administration record with the prescriptions on
the transfer orders.

62. A nurse on a medical surgical unit is caring for four clients. The nurse should recognize
that which of the following clients is the highest priority?
Answer: A. A client who is postoperative following a laminectomy 12 hr. ago and is unable
to void.

63. A nurse in an emergency department admits a client who has been exposed to cutaneous
anthrax. Which of the following actions should the nurse take?
Answer: A. Prepare to administer antibiotics to the client.

64. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts.
Which of the following actions should the nurse take first?
Answer: A. Determine the reasons the nurses are not taking their scheduled breaks.

65. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse
distracts the client and quickly administers the injection. This illustrates which of the
following?
Answer: A. Battery

66. A nurse is speaking with a visitor who asks a question about the status of a relative who is
a client on the unit. Which of the following responses by the nurse is appropriate?
Answer: A. “Please ask your relative about this, because I cannot share this information
about her.”

67. A nurse suggests respite care for the partner of a client who has mild cognitive
impairment. The client’s partner asks the nurse how that would help. The nurse should
explain that respite care would do which of the following?
Answer: A. Allow her to take time off from attending to her partner.

68. A charge nurse observes a client fall during ambulation and notes that his gait belt was not
in place. In reviewing the incident report, the nurse finds no mention of the gait belt. Which
of the following ethical principles should guide the nurse’s subsequent actions?
Answer: A. Veracity

69. A nurse is caring for a client who is scheduled for placement of a central venous access
device. Which of the following actions is the nurse’s responsibility in the informed consent
process?
Answer: A. Assess the client’s understanding after the provider has talked to her.

70. A nurse is providing teaching to assistive personnel about the application of wrists
restraints to a client. Which of the following instructions should the nurse include in the
teaching?
Answer: A. Remove the client’s restraints every 2 hr.