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ATI Leadership NURSING Proctored Exam Converted 1 of 3
Community Health Nursing (Alcorn State University)
ATI Leadership Proctored Exam
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 new scheduling system immediately before it
implementation
C. Introduce the new scheduling system by describing how it will save the institution money
D. Offer to reassign staff who do not support the change to another unit
Answer: A. Identify nurses who accept the change to help influence other staff nurses
Rationale:
Identifying nurses who accept the change can create a group of champions who can
positively influence their peers. This strategy leverages the principle of social influence to
help others embrace the new system.
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 has been initiated
C. The route of antibiotic therapy on the care pathway was changed from IV to PO
D. An allergy to penicillin required an alternative antibiotic to be prescribed.
Answer: C. The route of antibiotic therapy on the care pathway was changed from IV to PO
Rationale:
Changing the route of antibiotic therapy from intravenous (IV) to oral (PO) deviates from the
standard care pathway and may require a variance report to document the deviation and the
reason for the change.
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 med 30 min late
Answer: B. A visitor pinches his finger in the client's bed frame
Rationale:
An incident report is required for any unexpected event that results in or has the potential to
result in harm to a client, visitor, or staff member. The visitor pinching his finger in the
client's bed frame constitutes an unexpected event that could lead to harm and therefore
requires an incident report.
4. Client satisfactory surveys from a med-surg unit indicate the pain is not being adequately
relieved during the first 12 hr post-opt. The unit manager decides to identify post-opt pain as
a quality indicator. Which of the following data sources will be helpful in 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: A. Prospective chart audit
Rationale:
A prospective chart audit involves reviewing patient records in real-time to assess adherence
to protocols and guidelines. This method can provide insights into current practices and
identify areas for improvement in pain management after surgery.
5. A nurse precepting a newly licensed nurse who is caring for a client who is confused and
has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to
prevent dislodging the IV catheter. Which of the following questions should the precepting
nurse ask?
A. “Did you secure the restraints to the side rails of the bed?”
B. “Are you able to insert two fingers between the restraint and the client's skin?”
C. “Did you tie the restraints using a double knot?”
D. “Are you removing the client's restraints every 4 hours?”
Answer: B. “Are you able to insert two fingers between the restraint and the client's skin?”
Rationale:
This question assesses whether the restraints are applied correctly and not too tightly, which
is important to prevent injury and ensure patient safety.
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 is caring for the client is able to be
present for consultation
B. Provide the consultant with subjective opinions and beliefs about the client's wound care
C. Request the consultation after several wound care treatments are tried
D. Arrange for the wound care nurse specialist to see the client daily to provide the
recommended treatment
Answer: A. Arrange the consultation for a time when the nurse is caring for the client is able
to be present for consultation
Rationale:
This action ensures that the nurse can actively participate in the consultation, ask questions,
and understand the recommended treatment plan, which is essential for continuity of care.
7. A client is admitted with TB and placed in a negative pressure room. Which of the
following actions is appropriate?
A. Notify the local health department of the admission
B. Place a sign on the client’s door with the diagnosis
C. Ensure that admitting staff undergo PPD skin tests
D. Determine who had contact with the client in the last 48 hours
Answer: A. Notify the local health department of the admission
Rationale:
This action is important for public health surveillance and control of infectious diseases like
tuberculosis. The local health department can provide guidance on appropriate measures to
prevent the spread of TB.
8. A nurse is caring for a client who is unconscious and whose partner is the health care
proxy. The partner has spoken with the provider and wishes to discontinue the client's feeding
tube. The provider states to the nurse, “I will not discontinue the client's treatment. His
partner has no right to make decisions regarding the client's care.” Which of the following
responses by the nurse is appropriate?
A. You should consider speaking with the facility’s ethics committee before making your
decision
B. You have the right to make decisions, even if the partner is the client's health care proxy
C. The client has designated his partner as health care proxy in his advance directives
D. We'll need to have the nursing supervisor review the client's advance directives
Answer: A. You should consider speaking with the facility’s ethics committee before making
your decision
Rationale:
In this situation, it is important to involve the facility's ethics committee to ensure that the
client's wishes, as outlined in advance directives and represented by the health care proxy, are
respected and followed.
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. Lab test scheduled for the next shift
D. Reddened area on the coccyx
Answer: A. Glasgow Coma scale score
Rationale:
The Glasgow Coma Scale score is a critical indicator of neurological status, especially in
clients with increased intracranial pressure. Any changes in the score can indicate a
deterioration in the client's condition and require immediate attention.
10. A nurse is assigned the following four clients for the current shift. Which of the following
clients should the nurse assess first?
A. A client who has a hip fracture and is in Buck's traction
B. A client who has aspiration pneumonia and a respiratory rate of 28/min
C. A client who has diabetes mellitus with a stage 2 pressure ulcer on his foot
D. A client who has a C diff infection and needs a stool specimen collected
Answer: B. A client who has aspiration pneumonia and a respiratory rate of 28/min
Rationale:
Aspiration pneumonia with an elevated respiratory rate indicates a potentially serious
respiratory problem requiring immediate assessment and intervention to prevent respiratory
compromise.
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 minutes. Which of the following actions should the nurse take?
A. Notify the nursing supervisor about the issues
B. Contact the client's physical therapist
C. Apply a warm compress to the hip
D. Reposition the client for comfort
Answer: A. Notify the nursing supervisor about the issues
Rationale:
In this situation, the nurse should escalate the issue to the nursing supervisor to ensure timely
communication with the provider and appropriate management of the client's pain and hip
injury.
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 clients with cancer lose their hair
C. The nurse informs the next shift nurse regarding the mother's concerns
D. The nurse suggests counseling for the client's body image issues
Answer: A. The nurse investigates potential resources to help the client purchase a wig
Rationale:
Advocacy involves supporting the client's needs and preferences. In this case, the nurse
should explore resources to help the client with her body image concerns, such as finding a
wig.
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 post-op
B. A bed sheet from a client with bacterial pneumonia
C. A perineal pad from a client who is 24-hour post-vaginal delivery
D. An empty IV bag removed from a client who has HIV
Answer: C. A perineal pad from a client who is 24-hour post-vaginal delivery
Rationale:
Biohazard waste includes items contaminated with blood or body fluids, such as a perineal
pad from a post-vaginal delivery client. The other options do not necessarily require disposal
in a biohazard waste receptacle.
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 is appropriate?
A. "So you are upset about all the changes on the unit"
B. "I think you have a right to be upset, I am tired of the changes too"
C. "Just stick with it a little longer. Things will get better soon"
D. "You should file complaints with the hospital administrator"
Answer: B. "I think you have a right to be upset, I am tired of the changes too"
Rationale:
This response validates the nurse's feelings and shows empathy, which can help improve
communication and understanding between the nurse and the manager.
15. According to the HIPAA regulations, which of the following is a violation of client
confidentiality?
A. Telephone the pharmacy with a prescription for the spouse to pick up
B. Providing a copy of the record to the transporting paramedic
C. Reporting a client's disposition to the referring provider
D. Informing housekeeping staff that the client is in the dialysis unit
Answer: A. Telephone the pharmacy with a prescription for the spouse to pick up
Rationale:
HIPAA regulations prohibit disclosing protected health information (PHI) to individuals not
involved in the client's care, such as a spouse picking up a prescription without proper
authorization.
16. A Nurse preceptor is evaluating a newly licensed nurse's competency in assisting with a
sterile procedure. Which of the following actions indicates the nurse is maintaining sterile
technique? (Select all that apply.)
A. Open the sterile pack by first unfolding the flap farthest from her body
B. Rests the cap of a solution container upside down on the sterile field
C. Removes the outside packaging of a sterile instrument before dropping it into the sterile
field
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field
E. Places sterile items within a 1.25 cm (0.5 inch) border around the edge of the sterile field
Answer: A. Open the sterile pack by first unfolding the flap farthest from her body
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field
E. Places sterile items within a 1.25 cm (0.5 inch) border around the edge of the sterile field
Rationale:
A. Opening the sterile pack by first unfolding the flap farthest from the body helps maintain
sterility by minimizing the risk of contamination.
D. Holding a bottle of sterile solution 15 cm (6 inches) above the sterile field helps prevent
contamination by ensuring that the solution does not touch non-sterile surfaces.
E. Placing sterile items within a 1.25 cm (0.5 inch) border around the edge of the sterile field
helps maintain sterility by keeping the items within the sterile area.
17. A nurse is providing care for 4 post-op clients. The nurse should first assess the client
A. Whose pulse has been steadily increasing during the past shift
B. Who is reporting a pain level of 8 on a scale of 0 to 10
C. Whose urine output averaged 32 ml/hr for the past 24 hours
D. Who is reporting nausea after the prescribed antiemetic was administered
Answer: B. Who is reporting a pain level of 8 on a scale of 0 to 10
Rationale:
Pain assessment and management are a priority in post-operative care to ensure the client's
comfort and well-being. A pain level of 8 indicates significant discomfort and requires
immediate attention.
18. A nurse is preparing to transcribe a client's med prescription in the medical record. Which
of the following should the nurse recognize as containing the essential components of a
medication order?
A. NPH insulin 10 Units before and at bedtime
B. Haloperidol (Hadol) 1 mg per mouth
C. Multivitamin every morning by mouth
D. Aspirin 650 mg by mouth every 4 hours
Answer: A. NPH insulin 10 Units before and at bedtime
Rationale:
A complete medication order should include the medication name, dose, route, frequency,
and indication. The order for NPH insulin includes all these components.
19. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse
is having trouble focusing and has difficulty completing care for his assigned clients. Which
of the following interventions is appropriate?
A. Recommend that he takes time to plan at the beginning of the shift
B. Advise him to complete less time-consuming tasks first
C. Ask other staff members to take over some of his tasks
D. Offer to provide care for his clients while he takes a break
Answer: A. Recommend that he takes time to plan at the beginning of the shift
Rationale:
Planning at the beginning of the shift can help the newly licensed nurse prioritize tasks and
improve focus, which may help in completing care for assigned clients more efficiently.
20. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid
chemical in an industrial setting. Which of the following actions should the nurse take first?
A. Remove the client's clothing
B. Irrigate the exposed area with water
C. Report the incident to OSHA
D. Put on personal protective equipment
Answer: D. Put on personal protective equipment
Rationale:
The nurse's safety is a priority when dealing with hazardous substances. Putting on personal
protective equipment is the first step to protect oneself from exposure before providing care
to the client.
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 a terminal illness and respirations of
8/min
C. A nurse explains to a client's family that a DNR order includes withholding comfort
measures
D. A nurse informs a confused client who wants to go home that he is going to stay at the
facility until he is better
Answer: C. A nurse explains to a client's family that a DNR order includes withholding
comfort measures
Rationale:
A Do-Not-Resuscitate (DNR) order does not mean withholding comfort measures. It
indicates that the client does not want resuscitative measures such as CPR if their heart stops.
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: C. Establishing communication between providers
Rationale:
One of the objectives of telehealth is to facilitate communication between healthcare
providers, allowing for collaboration and coordination of care.
23. Which of the following puts a hospital at the highest risk of infringement of client record
confidentiality?
A. A nurse clusters documentation of care for multiple clients
B. A provider and nurse access client info using one access code
C. Paper-based charts are stored at the nurse's station
D. A nurse performs electronic documentation outside a client's room
Answer: B. A provider and nurse access client info using one access code
Rationale:
Sharing access codes between providers and nurses can lead to unauthorized access to client
records, increasing the risk of confidentiality breaches.
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 TB before transport to the radiology department
Answer: C. A nurse disconnects an indwelling urinary catheter from the drainage bag to
collect a specimen
Rationale:
Disconnecting an indwelling urinary catheter from the drainage bag can introduce bacteria
into the urinary tract, increasing the risk of infection. Safe handling techniques involve using
aseptic technique and following appropriate procedures for specimen collection.
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 parents enter the hospital room
C. An adolescent admitted to the emergency room won't speak to his parents
D. A preschool child who was previously toilet trained now requires diapers in the hospital
Answer: A. A school-age child has several bruises on her lower legs
Rationale:
Bruising on a school-age child's lower legs may raise suspicion of abuse, especially if the
bruises are not consistent with normal childhood injuries and are in various stages of healing.
26. A parish nurse is making a referral to a community meal delivery program for a member
of the congregation. This is an example of which of the following functions of the parish
nurse?
A. Liaison
B. Pastoral care provider
C. Health educator
D. Personal health counselor
Answer: A. Liaison
Rationale:
A parish nurse acts as a liaison between community resources and members of the
congregation to facilitate access to services such as meal delivery programs.
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 dilated pupils
Answer: A. A client who reports substernal chest pain radiating to the neck
Rationale:
Substernal chest pain radiating to the neck can indicate a possible myocardial infarction
(heart attack), which is a life-threatening condition that requires immediate medical attention.
28. A nurse manager overhears a provider and a staff nurse talking about a client's diagnosis
in the cafeteria. Which of the following actions should the nurse take first?
A. Provide a staff in-service about client confidentiality
B. Report the incident to the nursing supervisor
C. Remind them that the client info is confidential
D. Fill out an incident report regarding the situation
Answer: C. Remind them that the client info is confidential
Rationale:
The first action should be to remind the individuals that discussing a client's diagnosis in a
public area violates client confidentiality and to ensure that they understand the importance of
maintaining confidentiality.
29. A client with a substance use disorder is admitted to the mental health unit and reports
that he has been depressed lately. When preparing for discharge the next day, the client states:
"It's OK. Soon everything will be just fine." Which of the following is the nurse's primary
first action?
A. Ask the client if he has considered hurting himself
B. Provide the client with information about Alcoholics Anonymous
C. Encourage the client to participate in physical activities
D. Reinforce the need to follow up with the discharge referral
Answer: A. Ask the client if he has considered hurting himself
Rationale:
The client's statement may indicate suicidal ideation, so the nurse's primary action should be
to assess the client's risk of self-harm or suicide.
30. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse
distracts the client and quickly administers the injection. This illustrates which of the
following?
A. False imprisonment
B. Battery
C. Assault
D. Libel
Answer: B. Battery
Rationale:
Battery is the act of intentionally touching another person without consent. In this case,
administering the medication without the client's consent constitutes battery.
31. A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of
the following actions should the nurse manager take first?
A. Report the situation to the director of nursing
B. Have a blood alcohol level drawn from the nurse
C. Document a factual description of the situation
D. Remove the nurse from the unit
Answer: C. Document a factual description of the situation
Rationale:
The nurse manager should first document the observation of alcohol smell on the nurse's
breath. This documentation should be factual and include details such as the time, location,
and any other relevant information.
32. 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 respiratory disorders?
A. Asthma
B. Hyperventilation
C. Stridor
D. Atelectasis
Answer: A. Asthma
Rationale:
A paper bag at the bedside is often used in the treatment of asthma attacks to help the client
breathe into and out of the bag, which can help regulate breathing and reduce
hyperventilation.
33. A nurse is preparing to discharge a client back to a long-term care facility after he was
admitted to an acute care facility 2 days ago for pneumonia. Which of the following
information should the nurse include in the verbal transfer report?
A. Lab results within the expected reference range
B. List of regularly prescribed medications
C. Date of last bowel movement
D. Level of consciousness
Answer: B. List of regularly prescribed medications
Rationale:
Providing a list of regularly prescribed medications is essential for continuity of care and
ensuring that the client receives the appropriate medications upon return to the long-term care
facility.
34. A nurse who is precepting a newly licensed nurse is discussing the client assignment for
the shift. Which of the following actions should the nurse preceptor take first to demonstrate
appropriate time management?
A. Review the client's new lab values
B. Document assessment data
C. Complete required tasks
D. Determine client care goals
Answer: C. Complete required tasks
Rationale:
Completing required tasks first demonstrates appropriate time management, ensuring that
essential duties are accomplished in a timely manner.
35. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of
the following statements by the newly licensed nurse indicates an understanding of isolation
guidelines?
A. "I will instruct visitors to wear a mask when visiting a client who is on contact precaution"
B. "I will place a client who has compromised immunity in a negative-pressure airflow room"
C. "I will wear an N-95 respirator mask when caring for a client who is on droplet
precaution"
D. "I will have a client who is on airborne precautions wear a mask when out of her room"
Answer: A. "I will instruct visitors to wear a mask when visiting a client who is on contact
precaution"
Rationale:
Contact precautions require visitors and healthcare workers to wear masks and gowns when
entering the client's room to prevent the spread of infectious agents.
36. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is
appropriate to delegate to a licensed practical nurse?
A. Changing the dressing on a postoperative wound
B. Referring a client to social services for assistance with transportation
C. Instructing a client who is obese about a low-fat diet
D. Providing the first oral feeding to a client following a stroke
Answer: A. Changing the dressing on a postoperative wound
Rationale:
Changing a dressing on a postoperative wound is within the scope of practice for a licensed
practical nurse (LPN) and does not require the advanced skills of a registered nurse (RN).
37. A case manager working in a rehabilitation unit is discharging to home a client who has a
spinal cord injury at level C-7. Which of the following is the priority action in creating the
discharge plan?
A. Selecting strategies for cost-effective home care
B. Identifying the client's ability to perform activities of daily living
C. Providing educational handouts related to care requirements
D. Recommending community resources available to assist with client care
Answer: B. Identifying the client's ability to perform activities of daily living
Rationale:
Identifying the client's ability to perform activities of daily living is a priority because it will
help determine the level of assistance and support the client will need upon discharge.
38. A nurse is preparing to complete morning assessments on several assigned clients. Which
of the following clients should the nurse plan to assess first?
A. A client who has a nasogastric tube to intermittent suction and reports nausea
B. A client who has an early morning blood glucose of 220 mg/dL
C. A client who had a bladder scan that indicated 250 mL of urine in the bladder
D. A client who is 3 days postoperative and whose dressing has serosanguinous drainage
Answer: A. A client who has a nasogastric tube to intermittent suction and reports nausea
Rationale:
This client requires immediate assessment due to the nasogastric tube and reported nausea,
which could indicate a potential complication.
39. A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
A. Planning break times for assistive personnel
B. Picking up the meal trays after lunch
C. Administering a nasogastric tube feeding
D. Determining the adequacy of ventilator settings
Answer: C. Administering a nasogastric tube feeding
Rationale:
Administering a nasogastric tube feeding is within the scope of practice for a licensed
practical nurse (LPN) and does not require the advanced skills of a registered nurse (RN).
40. 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
Rationale:
Frequent dressing changes require nursing judgment and assessment skills, which are within
the scope of practice for an LPN. The LPN can perform this task safely and effectively.
41. A nurse is caring for 4 clients. Which of the following tasks can be delegated to an
assistive personnel?
A. Assessing a client who just returned from hemodialysis
B. Reviewing dietary instructions for a client with kidney stones
C. Obtaining a stool sample from a client with renal failure
D. Monitoring a client with a fluid restriction
Answer: D. Monitoring a client with a fluid restriction
Rationale:
Monitoring a client with a fluid restriction involves routine measurements and observations
that can be safely delegated to an assistive personnel (AP) under the direction and
supervision of the nurse.
42. A charge nurse is making rounds observes that an assistive personnel (AP) has applied
wrist restraints to a client who is agitated and does not have a prescription for restraints.
Which of the following actions should the nurse take first?
A. Inform the unit manager of the incident
B. Remove the restraints from the client's wrists
C. Speak with the AP about the incident
D. Review the chart for non-restraint alternatives for agitation
Answer: B. Remove the restraints from the client's wrists
Rationale:
The first priority is to ensure the client's safety by removing the restraints. Restraints should
only be applied with a valid physician's order and according to facility policy.
43. A client is brought to the emergency department (ED) following a motor-vehicle crash.
Drug use is suspected in the crash, and a voided urine specimen is ordered. The client
repeatedly refuses to provide the specimen. Which of the following is the appropriate action
by the nurse?
A. Document the client's refusal in the chart
B. Tell the client that a catheter will be inserted
C. Obtain a provider's prescription for a blood alcohol level
D. Assess the client for urinary retention
Answer: A. Document the client's refusal in the chart
Rationale:
The nurse should respect the client's autonomy while ensuring that the refusal is documented
appropriately in the chart.
44. Nurses on an inpatient care unit are working to help reduce unit costs. Which of the
following is appropriate to include in the cost-containment plan?
A. Use clean gloves rather than sterile gloves for colostomy care
B. Wait to dispose of sharps containers until they are completely full
C. Return unused supplies from the bedside to the unit's supply stock
D. Store opened bottles of normal saline in a refrigerator for up to 48 hours
Answer: C. Return unused supplies from the bedside to the unit's supply stock
Rationale:
Returning unused supplies from the bedside to the unit's supply stock helps reduce waste and
unnecessary expenditure on supplies.
45. An older adult client is awaiting surgery for a fractured right hip. The nurse should
recognize that which of the following can be delegated to an assistive personnel?
A. Turning the client
B. Recording the client's vital signs
C. Determining the client's pain level
D. Checking the pulses of the client's right foot
Answer: A. Turning the client
Rationale:
Turning the client is a task that can be safely delegated to assistive personnel, as long as they
have been trained in proper turning techniques and the client's condition allows for it.
46. To resolve a conflict between staff members regarding potential changes in policy, a nurse
manager decides to implement the changes she prefers regardless of the feelings of those who
oppose those changes. Which of the following conflict-resolution strategies in the nurse
manager using?
A. Compromising
B. Collaborating
C. Cooperating
D. Competing
Answer: D. Competing
Rationale:
Competing is a conflict-resolution strategy where one party insists on a preferred solution
without considering the concerns of others. This approach can lead to a win-lose outcome.
47. 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 med-surg unit?
A. A client who has gestational diabetes and is receiving biweekly nonstress tests
B. A primigravida client who is 1 day post-opt following a cesarean section and has a PCA
pump
C. A multigravida client who has preemclampsia and is receiving mistoprostol (Cytotec) for
induction of labor.
D. A client who is at 32 weeks of gestation and has premature rupture of membranes.
Answer: C. A multigravida client who has preeclampsia and is receiving misoprostol
(Cytotec) for induction of labor.
Rationale:
A client with preeclampsia requiring induction of labor is a high-risk patient who would
benefit from the skills and experience of an RN who has floated from a med-surg unit.
48. A nurse working on a med-surg unit is managing the care of 4 clients. The nurse should
schedule an interdisciplinary conference for which of the following clients?
A. A client who is at risk for pressure ulcers and has an albumin of 4.2 g/dl
B. A client who has type 1 DM and uses an insulin pump
C. A client who has orthostatic hypotension and is receiving IV fluids.
D. A client who is receiving heparin and has an aPTT of 34 seconds
Answer: A. A client who is at risk for pressure ulcers and has an albumin of 4.2 g/dl
Rationale:
This client is at risk for pressure ulcers, and an interdisciplinary conference would be
beneficial to develop a comprehensive care plan to prevent pressure ulcers.
49. A charge nurse is assessing staff knowledge about safety procedures regarding needlestick
injuries. Which of the following statements by a nurse indicates appropriate understanding of
these safety procedures?
A. Prophylactic treatment should be initiated after a needlestick during preparation of an
injection
B. I should stop the bleeding as soon as possible following a needlestick injury
C. An incident report should be completed if a client receives a stick from her own used
needle
D. The needle should be recapped to prevent injury during transport to the biohazard
container.
Answer: B. I should stop the bleeding as soon as possible following a needlestick injury
Rationale:
Stopping the bleeding is an immediate action to reduce the risk of bloodborne pathogen
transmission following a needlestick injury.
50. A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a
licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks
should the nurse assign to the LPN?
A. Obtaining a urine specimen from an older adult client
B. Providing postmortem care for a client who has just died
C. Accompanying a client who just had a wound debridement to physical therapy
D. Reinforcing dietary teaching with a client who has heart disease
Answer: D. Reinforcing dietary teaching with a client who has heart disease
Rationale:
Reinforcing dietary teaching is within the scope of practice for an LPN and does not require
the higher level of assessment and intervention skills of an RN.
51. A nurse enters the room of a client who is unconscious and finds that the client's son is
reading her electronic medical records from a monitor located at the bedside. Which of the
following actions should the nurse take first?
A. Recommend the son meet with the provider to get info about his mother's condition
B. Complete an incident report regarding the breach of the client's confidentiality
C. Log out of the computer so that the client's son is unable to view his mother's info
D. Report the possible violation of client confidentiality to the nurse manager
Answer: C. Log out of the computer so that the client's son is unable to view his mother's info
Rationale:
The immediate action should be to protect the client's confidentiality by ensuring
unauthorized access to the medical records is prevented.
52. A home health nurse is assessing the home environment of a client who is on continuous
oxygen therapy. Which of the following findings requires the nurse to intervene?
A. The oxygen machine has a grounded plug
B. The family keeps a spare oxygen tank in the room
C. The windows of the client's room are open
D. The client is covered with a woolen blanket
Answer: D. The client is covered with a woolen blanket
Rationale:
Woolen blankets can generate static electricity, which poses a risk in an oxygen-enriched
environment. Clients on oxygen therapy should use cotton fabrics and blankets to reduce the
risk of fire.
53. A nurse is teaching a client how to use a finger stick glucometer at home. Which of the
following instructions should the nurse include?
A. Elevate the arm for 1 min before taking the blood sample
B. Cap the lancet prior to putting it in the trash
C. Obtain the blood sample from the finger pads
D. Warm the hands prior to piercing the skin
Answer: B. Cap the lancet prior to putting it in the trash
Rationale:
Proper disposal of lancets reduces the risk of accidental needlesticks and infection
transmission.
54. A nurse in the emergency department is preparing to care for a client who arrived via
ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following
actions should the nurse take?
A. Contact the client's next of kin to obtain consent for treatment
B. Proceed with treatment without obtaining written consent
C. Have the client sign a consent for treatment
D. Notify risk management before initiating treatment
Answer: B. Proceed with treatment without obtaining written consent
Rationale:
In emergency situations where the client is unable to provide consent, treatment can be
initiated based on implied consent to prevent further harm.
55. A client has a new permanent pacemaker inserted. Which of the following home care
instructions should the nurse include?
A. The client should avoid using a microwave oven to heat food
B. Regular programming evaluations can be conducted by telephone
C. The client should avoid using remote control devices to prevent dysrhythmias
D. Suctioning could cause the unit to have an electrical shock
Answer: C. The client should avoid using remote control devices to prevent dysrhythmias
Rationale:
Remote control devices can interfere with the pacemaker's function and should be avoided.
56. While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that 6 of the 15 records lack documentation regarding advance directives.
Which of the following is the priority action for the nurse to take?
A. Reinforce the potential consequences of not having this info on record to the nursing staff.
B. Ask the nurses who are caring for clients without this info in the medical record to obtain
it.
C. Meet with nursing staff to review the policy regarding advance directives.
D. Remind nurses to obtain this info during the admission process.
Answer: C. Meet with nursing staff to review the policy regarding advance directives.
Rationale:
The priority is to address the systemic issue by reviewing the policy with the nursing staff to
ensure they understand and adhere to the procedure for documenting advance directives.
57. A client is admitted with COPD. Which of the following findings should the nurse report
to the provider?
A. Oxygen saturation 89% on room air.
B. WBC count 9,000/mm
C. Report of dyspnea on exertion
D. Bilateral crackles on auscultation of lungs.
Answer: A. Oxygen saturation 89% on room air.
Rationale:
Oxygen saturation below 90% indicates hypoxemia, which requires immediate intervention
and should be reported to the provider.
58. A charge nurse notices 2 staff nurses are not taking meal breaks during 8-hr shifts. Which
of the following actions should the nurse take first?
A. Provide coverage for the nurse s‟ breaks.
B. Determine the reasons the nurses are not taking scheduled breaks.
C. Discuss time management strategies with the nurses.
D. Review facility policies for taking scheduled breaks.
Answer: B. Determine the reasons the nurses are not taking scheduled breaks.
Rationale:
Before taking action, it's important to understand why the nurses are not taking breaks, which
could be due to workload, time management issues, or other factors.
59. A nurse is caring for a client who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted in regard to this client s‟ care? (Select
all that apply.)
A. Occupational therapist
B. Nutritional therapist
C. Physical therapist
D. Mental Health counselor
E. Case manager
Answer: B. Nutritional therapist
D. Mental Health counselor
Rationale:
• B. Nutritional therapist: Anorexia nervosa often involves severe nutritional deficiencies and
distorted eating behaviors. A nutritional therapist can help develop a structured and healthy
eating plan to address these issues.
• D. Mental Health counselor: Anorexia nervosa is a complex mental health disorder that
requires psychological intervention. A mental health counselor can provide therapy to address
the underlying emotional and psychological factors contributing to the disorder.
60. A nurse manager is reviewing guidelines for informed consent with the nursing staff.
Which of the following statements by a staff nurse indicates that the teaching was effective?
A. Guardian consent is required for an emancipated minor
B. Consent can be given by a durable power of attorney.
C. A family member can answer any questions the client has about the procedure.
D. The nurse can answer any questions the client has about the procedure
Answer: A. Guardian consent is required for an emancipated minor
Rationale:
This statement demonstrates an understanding of the requirements for informed consent for
an emancipated minor.
61. A nurse on a medical-surgical unit is caring for 4 clients. This nurse should recognize that
which of the following clients is the highest priority?
A. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy.
B. A client who has peripheral vascular disease and has absent pedal pulse in right foot.
C. A client who is post-op following a laminectomy 12 hr ago and is unable to void.
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temp of 38 degrees C (101 F).
Answer: D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an
axillary temp of 38 degrees C (101 F).
Rationale:
This client has MRSA, indicating an infection, and an elevated temperature, indicating a
systemic response. Infections can quickly become serious, especially in clients with MRSA,
so this client should be the priority to prevent further complications.
62. 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."
B. "This won't take long and it will be over before you know it."
C. "Why did you make the decision to have this procedure?"
D. "You shouldn't be worried because the procedure is very safe."
Answer: B. "This won't take long and it will be over before you know it."
Rationale:
This response acknowledges the client's emotions while providing reassurance about the
procedure's duration, which may help alleviate anxiety.
63. A nurse working in the emergency department is assessing several clients. Which of the
following clients is the highest priority?
A. A client who has a raised red skin rash on his arms, neck, and face.
B. A client who reports right-sided flank pain and is diaphoretic.
C. A client who reports shortness of breath and left neck and shoulder pain.
D. A client who has active bleeding from a puncture wound of the left groin.
Answer: D. A client who has active bleeding from a puncture wound of the left groin.
Rationale:
Active bleeding is a life-threatening emergency that requires immediate attention to control
the bleeding and prevent further complications.
64. 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 in the quality improvement process?
A. Review current literature regarding client falls.
B. Implement a fall prevention plan.
C. Notify staff of the increased fall rates.
D. Identify clients who are at risk for falls.
Answer: D. Identify clients who are at risk for falls.
Rationale:
The first step in addressing an increase in client falls is to identify those at risk. This will help
target interventions effectively to prevent future falls.
65. 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.)
A. Selects the dorsogluteal site to administer the injection.
B. Cleans the injection site with alcohol.
C. Applies gentle pressure at the site after injection.
D. Aspirates the syringe for blood return after needle insertion.
E. Inserts the needle at a 45-degree angle.
Answer: B. Cleans the injection site with alcohol.
C. Applies gentle pressure at the site after injection.
Rationale:
Cleaning the injection site with alcohol helps prevent infection. Applying gentle pressure at
the site after injection can help minimize bleeding and discomfort for the newborn. The
dorsogluteal site is not recommended for newborns. Aspirating the syringe for blood return is
not necessary for intramuscular injections in newborns. The needle should be inserted at a 90degree angle for intramuscular injections.
66. A nurse enters a client's room and observes a fire in a trash can. Identify the sequence of
actions the nurse should take. (Move all the actions into the box on the right, placing them in
the selected order of performance.)
1. Remove the client from the area
2. Activate the fire alarm system
3. Confine the fire by closing doors and windows
4. Extinguish the fire if possible
Answer: To respond effectively to a fire in a client's room, a nurse should follow these steps
in the specified order:
1. Activate the fire alarm system to alert others in the facility.
2. Remove the client from the area to ensure their safety.
3. Confine the fire by closing doors and windows to prevent its spread.
4. Extinguish the fire if possible, using appropriate firefighting equipment or techniques.
Rationale:
• Activating the fire alarm system is the first step to alert others and initiate the facility's fire
response protocol. It ensures that help is on the way and that the fire department will be
notified.
• Removing the client from the area is critical for their safety. Moving the client away from
the fire reduces the risk of injury.
• Confining the fire by closing doors and windows helps prevent the fire from spreading to
other areas of the facility. This containment buys time for the fire department to arrive and
extinguish the fire.
• Extinguishing the fire if possible should only be attempted if it can be done safely and
within the nurse's training and capabilities. Personal safety should always come first, and if
the fire is too large or spreading rapidly, the nurse should evacuate the area and wait for
professional firefighters.
67. 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.
D. Threatening to apply wrist restraints to control a client who is agitated.
Answer: C. Inserting a feeding tube against the wishes of a client.
Rationale:
Battery is the intentional touching of another person without consent. In this case, inserting a
feeding tube against the client's wishes would be considered battery because it involves a
physical intervention without the client's consent.
