ATI RN LEADERSHIP

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

Pipe cleaners b. O2 Tank e. Obturator

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?

Place the client‟s ring in the facility safe.

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?

Request that the charge nurse modify the assignment.

A nurse in a long-term care facility should identify that which of the following will provide security for clients who have dementia?

Setting alarms on exits

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?

Log out the computer so that the client‟s son is unable to view his mother‟s information.

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?

Speech therapist

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 blood culture was obtained after antibiotic therapy had been initiated

A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority?

A client who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds

A nurse is caring for a group of clients. Which of the following clients should the nurse plan to assess first?

A client who has a nasogastric tube and has crackles in the lungs (ABC-- airway)

A nurse is caring for a group of clients. Which of the following should the nurse see first?

A client who has diabetes mellitus and is diaphoretic

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 client who has peripheral vascular disease ad has an absent pedal pulse in the right foot

A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?

A client who has two open chest wounds with a left tracheal deviation

A nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager assign to a float nurse from the medical-surgical unit?

A client who is 2 days post-operative following a caesarean birth and is having difficulty ambulating

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse care for first?

A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg

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 client who is receiving IV chemotherapy and is ambulatory

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 client who reports indigestion and pain in her jaw

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?

Perform a urinary catheterization for a client who has experienced a cerebrovascular accident.

A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

Performing post mortem care prior to transferring the client to the morgue

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 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

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 middle adult client who has a below the knee amputation and requires a dressing change

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?

Pertussis

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?

"Consent can be given by a durable power of attorney."

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?

"Hospice care is a multidisciplinary program for clients who are terminally ill."

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?

"I can leave my wedding ring on if it is taped in place"

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?

"I might have to wear a nose clip during this test."

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?

"I should have a sputum culture done every 2 to 4 weeks."

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?

"I will need assistance with bathing."

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?

"I will remove a client‟s restraints every 4 hours."

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?

"It makes it possible for you to have some time away from caring for your wife."

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?

"My durable power of attorney for health care is part of my advance directives"

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?

"My role as a client advocate is to empower the clients to make informed healthcare decisions."

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 client who has multiple sclerosis and ataxia

A charge nurse suspects that a staff nurse is chemically impaired. Which of the following actions should the charge nurse take?

. Collect data about the staff nurse to support further action

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?

. Position the client on her left side with knees flexed

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?

. Proceed with treatment without obtaining written consent (Implied Consent)

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 sufficient supply of personal protective equipment

A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls (SATA) [repeat]

A wheeled office chair at the client's computer desk A throw rug covering some cracked floor • A folding chair without arm rests

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?

Administer a hepatitis B vaccine.

A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse?

Administer a nasogastric tube feeding.

A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent?

An adolescent client who is legally emancipated

A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee?

An adolescent client whose parents refuse a blood transfusion for religious reasons

. A nurse in the emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first?

An older adult client who has dyspnea and a respiratory rate of 26/min

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?

Ask the client‟s son to go to the waiting area.

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?

Ask the nurse to describe her medication administration procedure.

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?

Assess the staff nurse‟s knowledge deficit

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?

Attempt to notify the client‟s guardian to obtain consent

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?

Auscultate the client‟s lungs.

. A nurse is prioritizing postpartum care for four clients. Which of the following actions should the nurse take first?

Check uterine tone for a client who received methylergonovine- if the uterine tone is not

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?

Chlamydia trachomatis

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?

Chlorine bleach

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?

Collaborating

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?

Collect urine specimen for newly admitted client

A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

Continue the medication dosages that relieve the client‟s pain.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?

Decreased level of consciousness

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.

Deep red color on the center of the clients wound

. 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?

Determine factors that interfere with the documentation of client education.

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?

Determine the reasons the nurses are not taking scheduled breaks. Assess first

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?

Discuss with the client her concerns regarding the procedure

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?

Document the client‟s refusal in the chart.

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?

Don personal protective equipment

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?

Escort the nurses to the nurses‟ lounge to continue the discussion.

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?

Establishing communication between providers

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?

Gather information regarding the situation

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?

Has data been collected about specific client needs related to turning? (Assessment of holistic care r/t pt needs and what the experienced AP can do)

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?

Identify clients who are at risk of falls

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?

Identify the industry standards for infant safety

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?

Infection control nurse

A nurse is providing information to a client about advance directives. The nurse should explain that advance directives include which of the following?

Instructions regarding treatments the client desires or does not desire - (livings wills and durable power of attorney make up AD)

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?

Libel : talking bad about someone via writing it in notes

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?

Measure the client‟s vital signs

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?

Meet with nursing staff to review the policy regarding advance directive

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?

Mumps

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?

Nonmaleficence

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?

Notify the provider about the client‟s concerns

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?

Observe the client‟s condition.

A nurse received change of shift report at 0700 for four clients. Which of the following actions should the nurse perform first?

Obtain a breakfast tray for a client who received a morning dose of insulin aspart

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?

Obtain the weight of a newborn that is receiving formula

A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel?

Obtaining a stool sample from a client who has renal failure

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)

Opens the sterile pack by first unfolding the top flap away from her body Removes the outside packaging of a sterile instrument before dropping it onto the sterile field

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?

Provide treatment for life-threatening injuries

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?

Recheck vital signs that are outside the expected reference range.

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?

Recommending a referral for a client who requires physical therapy

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?

Recording the client‟s vital signs

. 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?

Refer the AP to the facility procedure manual.

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?

Refer the client to the social services department

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?

Reinforcing teaching with a client who is learning to self-administer insulin

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?

Remind the client to change positions slowly.

A nurse is completing performance evaluation for an assistive personnel (AP). Which of the following actions by the AP requires intervention by the nurse?

The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile.

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

The client‟s bedside lamp is plugged in using an extension cord with two prongs

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?

The client‟s vital signs

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

The emergency department nurse is waiting to give report on a new admission

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?

The nurse holds her hands above her waist.

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?

Unilateral neglect -is one of the disabling features of stroke, and is defined as a failure to attend to the side opposite a brain lesion

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

Warm the hands prior to piercing the skin

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?

Wears gown when caring for client

. 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?

Whether the client understands the risk of refusing the procedure

A nurse is providing discharge teaching to a client following a total knee arthroplasty. Which of the following information should the nurse include (SATA

b. Contact information for the physical therapist c. Medication guidelines information e. Information about follow-up care

. 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?

c. Determine client care goals (set/plan goals)

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?

d. "HIPAA allows clients to request a review of their own medical records."

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?

d. Transport the client to the operating room without verifying informed consent.