ATI Management Practice Part B

A nurse at a rehab facility is supervising a newly hired assistive personnel (AP) during the transfer of a client from the bed to a chair. Which of the following actions by the AP demonstrates safe transfer technique? A. Bends at the Knees B. Twists at the Waist C. Maintains a Narrow Stance D. Leans Away from the Client

A. Bends at the Knees

A nurse is observing an AP provide care for a group of clients. The nurse should intervene when the AP dons gloves prior to performing which of the following tasks? A. Making a surgical bed for a client returning from surgery B. Emptying a client's urine collection bag C. Brushing a client's teeth D. Administering a commercially prepared enema

A. Making a surgical bed for a client returning from surgery

A nurse is assisting with triage following a mass casualty event. The nurse should recommend that which of the following clients be attended to first? A. A client who has partial-thickness burns to the arms and reports severe pain B. A client who has a crush injury to the pelvis and whose pedal pulse in the right foot are absent C. A client who has an open fracture of the femur and a 5.1cm(2in) laceration in the thigh D. A client who is unconscious with a closed head injury and whose pupils are fixed and dilated

B. A client who has a crush injury to the pelvis and whose pedal pulse in the right foot are absent

A nurse is reinforcing teaching about home safety with an older adult client. Which of the following client statements indicates an understanding of the teaching? A. "I will keep the temperature in my refrigerator at 45 degrees Fahrenheit." B. "I should secure extension cords to the floor with transparent tape." C. "I should participate in a supervised exercise program." D. "I will limit driving to the evening hours after traffic has slowed."

C. "I should participate in a supervised exercise program."

A newly licensed nurse is caring for a client who requires straight cath. The nurse informs the charge nurse that he has only observed the procedure on two occasions. Which of the following responses should the charge nurse make? A. "You should review the policy manual before performing the procedure'" B. "I'll assign this task to another nurse and you can observe." C. "Let's discuss the procedure and I'll assist you with it the first time'" D. "I'll suggest that you seek help from one of your more experienced colleagues."

C. "Let's discuss the procedure and I'll assist you with it the first time'"

A nurse is participating in a disaster drill and is assigned to assist with clients in the yellow tag staging area. The nurse should expect to assist in treating which of the following clients? A. A client who has closed fractures in both arms B. A client who has a large, open chest wound C. A client who has burns to the trunk and legs D. A client who has a penetrating head wound

C. A client who has burns to the trunk and legs

A nurse is completing documentation on the computer at the nurse's station when an assistive personnel (AP) requests to use the computer to enter the morning vital signs. Which of the following actions should the nurse take? A. Enter the AP's vital sign data for them B. Allow the AP to use the computer while the nurse is still logged in C. Ask the AP to find another computer D. Tell the AP to come back at a later time

C. Ask the AP to find another computer

A nurse is serving on a performance improvement committee which is reviewing client falls. The data shows that most falls occur between 2000 and 2200. Which of the following recommendations should the committee make? A. Assign clients who are disoriented to rooms away from the nurses' station B. Keep bedside tables with wheels away from the bed C. Check on the clients hourly D. Raise four side rails while clients are in bed

C. Check on the clients hourly

A nurse is preparing to reinforce discharge teaching with a client who speaks a different language than the nurse. The client has a new diagnosis of a diabetes and his partner is at the bedside. Which of the following actions should the nurse take? A. Ask the client's partner to translate written instructions for the client B. After giving instructions, ask the client if they understand the teaching C. Contact an interpreting service via telephone to assist with the instructions D. Direct instructions about insulin administration to the client's partner

C. Contact an interpreting service via telephone to assist with the instructions

A nurse is assisting an RN with developing a meal plan for a client who has neutropenia. Which of the following foods should the nurse recommend including in the meal plan? A. Soft-Boiled Eggs B. Spinach Salad C. Fried Fish D. Celery Stalks

C. Fried Fish

A nurse is assisting with the development of an in-service about the process of evidence-based practice. Which of the following actions should the nurse include as the first step of the process? A. Locate research articles in current scientific journals B. Critically examine the evident to determine if it is reliable C. Question a current clinical practice that does not seem effective D. Make changes to policies that reflect new evidence-based guidelines

C. Question a current clinical practice that does not seem effective

A nurse is contributing to the plan of care for a group of clients. Which of the following scenarios demonstrates effective use of time management techniques? A. The nurse finished collecting physical assessment date on a client who is resting quietly before checking on a client who reports nausea B. The nurse leaves the change-of-shift report early to begin client care activities C. The nurse groups activities for a surgical client based on the client's pain medication schedule D. The nurse waits to evaluate the client's care until the end of each shift

C. The nurse groups activities for a surgical client based on the client's pain medication schedule

A nurse is assisting with the development of a presentation for newly licensed nurses regarding client confidentiality. Which of the following actions should the nurse include as an example of a breach of client confidentiality? A. Logging in and out of the computer terminal after each data entry using a facility-specific universal passcode B. Refusing to share a personal passcode with a new provider who needs to access data about an urgent client C. Printing each assigned client's current medication list and shredding the documents at the end of the shift D. Accessing client medical records from other units to compare outcomes with currently assigned clients

D. Accessing client medical records from other units to compare outcomes with currently assigned clients

A nurse in a long-term care facility is caring for a client who is refusing their prescribed medications. Which of the following actions should the nurse take first? A. Notify the provider that the client is refusing their medications B. Document the client's refusal in the medication administration record C. Explain the benefits of the medications to the client D. Identify the client's concerns about taking the medications

D. Identify the client's concerns about taking the medications

A nurse realizes she has administered the wrong medication to a client. Which of the following actions should the nurse take first? A. Notify the charge nurse B. Check the client's MAR C. Complete an incident report D. Monitor the client's vital signs

D. Monitor the client's vital signs

A nurse is participating in discharge planning for a client who has a new tracheostomy. Which of the following equipment should the nurse ensure is available for providing care for the client at home? A. Endotracheal Tube B. Petroleum Gauze C. Sterile Povidone-Iodine D. Portable Suction

D. Portable Suction

A newly hired nurse recognizes that the unit staff and nurse manager seem to be in constant conflict. The nurse should identify that the nurse manager is using which of the following conflict management approaches when she decides that her plans are the best and the unit staff is no longer trying to resolve conflict? A. Win-Yield B. Lose-Lose C. Win-Win D. Win-Lose

A. Win-Yield

A nurse is supervising an AP who is faxing a client's morning laboratory results to a provider's office. Which of the following actions AP requires intervention by the nurse? A. Includes a cover sheet when faxing information B. Sends laboratory results from the past week C. Uses the fax machine at the nurses' station D. Dials with a programmed speed-dial

B. Sends laboratory results from the past week

A nurse is collecting data from a client following abdominal surgery. The nurse should identify that which of the following findings is the priority to report to the provider? A. Reports incisional pain during ambulation B. Inadvertent removal of an indwelling urinary catheter C. Surgical dressing saturated with bloody drainage D. Swelling at the IV catheter insertion site

C. Surgical dressing saturated with bloody drainage

A nurse is delegating tasks to assistive personnel (AP). Which of the following statements by the nurse includes the rights of delegation? A. "Take the vital signs of the clients in rooms 226 through 232 and evaluate any changes." B. "Turn the client in room 621 to prevent pressure areas on their hip bones and assess for edema." C. "Perform the glucose checks on time and replace the glucometer back into the charger when you finish." D. "Ambulate the client in room 316 to the end of the hall before lunch and report any shortness of breath."

D. "Ambulate the client in room 316 to the end of the hall before lunch and report any shortness of breath."

A charge nurse is discussing legal issues with a newly licensed nurse. Which of the following actions should the charge nurse identify as negligence? A. Failing to provide one-to-one observation for a client who is suicidal B. Speaking negatively about a provider's abilities to a client's family C. Signing the client's medical record as an LPN before taking the NCLEX-PN D. Inserting a urinary catheter in a competent client without consent

A. Failing to provide one-to-one observation for a client who is suicidal

A charge nurse notices a nurse on a unit arriving to work 30 min late. The nurse appears unkept and has slurred speech. Which of the following actions should the nurse take first? A. Reassign the nurse's clients to another nurse B. Support the nurse manager in reporting the incident to the board of nursing C. Offer emotional support to the nurse D. Document the incident for the nurse manager

A. Reassign the nurse's clients to another nurse

A nurse is assisting with the care of a client who suddenly becomes unconscious and requires emergency surgery. The client does not have advance directives and the only family member available is the client's 14-year-old daughter. Which of the following actions should the nurse plan to take? A. Transport the client to the operating room with implied consent B. Call the 14-year-old child to obtain informed consent C. Send an urgent request to the facilities ethics board D. Obtain a court order for the emergency surgery

A. Transport the client to the operating room with implied consent

A nurse is participating in a peer evaluation system based on the overall performance of its nursing staff. Which of the following strategies ensures peer evaluation process is impartial and fair? A. Uses the same objective measurement tool for all nurses B. Reviews personnel files for counseling forms and verbal or written warnings C. Designates experienced nurses to perform all peer evaluations D. Excludes nurses from the process if they are uncomfortable evaluating their peers

A. Uses the same objective measurement tool for all nurses

A nurse is assisting in planning care for a client who has heart failure. Which of the following interventions should the nurse recommend including in the plan? (Select all that apply) A. Restrict sodium intake to 4g per day B. Administer furosemide 40mg PO daily C. Place the client in supine position when in bed D. Apply oxygen to keep SpO2 greater than 95% E. Obtain daily weight

B. Administer furosemide 40mg PO daily D. Apply oxygen to keep SpO2 greater than 95% E. Obtain daily weight

A nurse is caring for a client who is recovering following a total hip arthroplasty. The nurse receives a telephone call from the client's sister requesting info about the client's status. Which of the following actions should the nurse take? A. Check the client's medical record to determine who the health care surrogate is B. Transfer the call to the client C. Ask the caller how urgent it is to have this information D. Transfer the call to the charge nurse

B. Transfer the call to the client

A nurse is assisting with a presentation about preparing a home disaster supply kit at a community health fair. Which of the following statements by a participant indicates an understanding of the information? A. "I will keep frozen vegetables available for the kit." B. "I will replace food items in the kit every 9 months." C. "I will have a 2-day supply of food in the kit." D. "I will purchase canned fruit for the kit."

D. "I will purchase canned fruit for the kit."

A nurse is verifying informed consent with a client who is scheduled to have a total open abdominal hysterectomy with bilateral salpingo-oophorectomy for the treatment of uterine cancer. The nurse should notify the provider for which of the client statements? A. "My parents are sad they won't have any more grandchildren." B. "I don't look forward to having menopause symptoms." C. "My recovery will be slower because of the abdominal incision." D. "I wish I knew if there was another way to treat this other than surgery."

D. "I wish I knew if there was another way to treat this other than surgery."

A nurse in a provider's office is reinforcing discharge teaching with an adult client who has a new prescription for ear drops for an inner ear infection. Which of the following instructions should the nurse include? A. "Hold the drops 4cm(1.6in) above the ear canal to instill the medication." B. Wait 1 minute before repositioning after instilling the ear drops." C. "Pull the tip of your ear backwards before instilling the ear drops." D. "Lie on your side when preparing to instill the ear drops."

D. "Lie on your side when preparing to instill the ear drops."

A nurse is discussing the meaning of utilitarianism with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates the understanding of this ethical theory? A. "Utilitarianism identifies the needs of the individual as priority." B. "Utilitarianism represents my duty to provide compassionate care to all clients." C. "Utilitarianism focuses on human dignity as its fundamental principle." D. "Utilitarianism provides the greatest good for the greatest number of people."

D. "Utilitarianism provides the greatest good for the greatest number of people."

A charge nurse in skilled care facility identifies an increased rate of client falls. Which of the following statements to the nursing staff indicated the charge nurse is addressing the problem with an authoritarian leadership style? A. "I've made it mandatory for all nursing staff to attend an educational session on reducing client falls." B. "I know this problem affects our entire nursing staff, so let's work together towards a goal of decreased client falls." C. "I'm turning over the problem of increased client falls to you, as the nursing staff, to address." D. "I'd like to have input from the entire nursing staff on how to address the problem of client falls."

A. "I've made it mandatory for all nursing staff to attend an educational session on reducing client falls."

A nurse is discussing time management with a newly licensed nurse. Which of the following actions should the nurse recommend managing time effectively? A. Establish Goals B. Create an Assignment Sheet C. Refer to the Critical Pathway D. Use a Flow Sheet

A. Establish Goals

A nurse is observing a newly licensed nurse administer ophthalmic medication to a client. Which of the following actions should the newly licensed nurse take first? A. Verify the medication with the client's MAR B. Cleanse the eye with a damp was cloth from the inner to the outer canthus C. Have the client sit in a chair and hyperextend their neck D. Apply gentle pressure to the lacrimal sac for 60 seconds

A. Verify the medication with the client's MAR

A nurse is delegating collection of a random stool specimen to an AP. Which of the following information should the nurse provide? A. Wrap tongue blades used to retrieve the specimen in a paper towel prior to disposal B. Collect pus from the stool with a sterile swab and place it in a sterile test tube C. Place chlorhexidine in the client's commode before they provide the sample D. Double-bag the specimen if it must be placed in a refrigerator containing medication

A. Wrap tongue blades used to retrieve the specimen in a paper towel prior to disposal

A nurse is assisting with the selection of clients to discharge to make beds available following a tornado in the community. Which of the following clients should the nurse recommend for discharge? A. A client who was admitted 24 hr ago for fluid volume deficit and now has a serum potassium level of 3.1mEq/L B. A client who is recovering from a laparoscopic appendectomy that was performed 24 hr ago C. A client who has uterine cancer and had intracavity of radiation 30 hr ago D. A client who was admitted 12 hr ago for heatstroke and has been rehydrated with 2,000mL of 0.9% sodium chloride

B. A client who is recovering from a laparoscopic appendectomy that was performed 24 hr ago

A nurse on a pediatric unit is assisting with the care of four clients. Which of the following clients should the nurse plan to see first? A. An infant who has rotavirus and watery diarrhea B. A preschooler who has respiratory syncytial virus and is wheezing C. A toddler who is in a hip spica cast and has had a bowel movement D. An adolescent who has sickle cell disease and is requesting pain medication

B. A preschooler who has respiratory syncytial virus and is wheezing

A nurse is assisting with the discharge of a client who was a in motor-vehicle crash 24 hr ago. the client tells the nurse, "My vision seems blurry, and I am having difficulty speaking clearly." Which of the following actions should the nurse make first? A. Document the client's statement in the medical record B. Check the client for indications of increased intracranial pressure C. Notify the charge nurse of the client's statement D. Instruct the client to remain in bed with the head elevated

B. Check the client for indications of increased intracranial pressure

A nurse is assisting in planning care for a client who has heart failure. Which of the following interventions should the nurse include? (Select all that apply) A. Require the client to complete new advance directives for this admission B. Document in the client's medical record that they have advance directives C. Ensure that copies of the client's advance directives are located in the chart D. Inform the oncoming nurse of the client's advance directives during change-of-shift report E. Contact the facility chaplain to discuss the advance directives with the client

B. Document in the client's medical record that they have advance directives C. Ensure that copies of the client's advance directives are located in the chart D. Inform the oncoming nurse of the client's advance directives during change-of-shift report

A charge nurse is asked by two staff nurses to assist in resolving a conflict about holiday scheduling. Which of the following actions should the charge nurse take? A. Negotiate with the two staff nurses at the nurses' station B. Encourage each staff nurse to give up something as part of the negotiation C. Explain to the staff nurses that the holiday schedule is nonnegotiable D. Resolve the conflict with a win-yield outcome

B. Encourage each staff nurse to give up something as part of the negotiation

A nurse is caring for a client who has COPD. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Checking the client's lung sounds B. Measuring the client's weight C. Reviewing the client's laboratory values D. Instructing the client in coughing and deep-breathing exercises

B. Measuring the client's weight

A nurse is providing care for a group of clients who have signed a general consent for treatment. The nurse should identify that which of the following procedures requires an additional written informed consent? A. Obtaining an MRi B. Performing an Amniocentesis C. Inserting an Indwelling Urinary Catheter D. Placing an NG Tube

B. Performing an Amniocentesis

A nurse in a long-term care facility is preparing to demonstrate administration of a cleansing enema to a group of newly licensed nurses. Which of the following actions should the nurse plan to take during the demonstration? A. Administer 500mL of Solution B. Place the client in a left-lying position C. Lubricate the tip pf the tube with petroleum jelly D. Insert the tip of the tube 12.7cm (5in) into the client's rectum

B. Place the client in a left-lying position

A nurse is reinforcing teaching with a newly licensed nurse about ethical principles to consider during client care. Which of the following actions should the nurse include as an example of client advocacy? A. Selecting a home health care agency for a client in preparation for discharge B. Relaying a client's concerns about an upcoming procedure to the provider C. Asking a client who is verbally abusing staff to explain why they are angry D. Encouraging a client who wants to stop renal dialysis to continue with treatment

B. Relaying a client's concerns about an upcoming procedure to the provider

A nurse is assisting with the care of an older adult client who is recovering from a stroke and is experiencing difficulty swallowing and performing ADLs. The client will be living with his adult son following discharge. The nurse should recognize that which of the following client referrals has the highest priority? A. Occupational Therapy B. Speech Therapy C. Social Services D. Adult Day Care

B. Speech Therapy

A nurses assisting with disaster triage is examining a client who has a large open wound to the lower extremity. Which of the following actions should the nurse take? A. Assign the client a black tag B. Tell the client they should receive treatment within 2 hours C. Inform the client that they are in the emergent category D. Apply an ice pack to the extremity

B. Tell the client they should receive treatment within 2 hours

A nurse at a rehabilitation facility is participating in an interprofessional care conference for a client who is 1 week post-op following an above the knee amputation. Which of the following findings is the priority for the nurse to report at the conference? A. The client is taking oral opioids to control pain B. The client's incision site has purulent drainage C. The client's home bathroom does not have grab bars D. The client refuses to look at their residual limb

B. The client's incision site has purulent drainage

A nurse is assisting with the development of a slide presentation for staff education about preventing medication errors. Which of the following actions should the nurse take when developing the slides? A. Select a white background with light-colored text B. Use sentences that have a maximum of six words C. Limit the number of lines to 10 per slide D. Place slide animations or video clips on each slide

B. Use sentences that have a maximum of six words

A nurse is contributing to the plan of care for a client who states he is a devout Hindu. To adhere to the client's religious dietary practices, which of the following food options should the nurse offer the client? A. Tomato Soup B. Yogurt C. Hamburger D. Pork Chop

B. Yogurt

A charge nurse is planning a discussion concerning scope of practice with a group of newly licensed practical nurses (LPNs). Which of the following tasks should the charge nurse identify as within the scope of the practice for an LPN? (Select all that apply) A. Plan nursing care for clients who have complicated diagnoses B. Delegate the care of a client to an RN C. Participate in health promotion counseling for a client D. Evaluate a client's response to nursing interventions E. Assist in the development of unit policies affecting client care

C. Participate in health promotion counseling for a client D. Evaluate a client's response to nursing interventions E. Assist in the development of unit policies affecting client care

A nurse is planning to delegate care for a group of clients following change-of-shift report. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? A. Setting up the sterile field for a client who is scheduled for a lumbar puncture B. Obtaining a wound culture from a client C. Reinforcing teaching with a client on how to perform coughing and deep-breathing exercises D. Applying bilateral sequential compression devices to a client's legs

D. Applying bilateral sequential compression devices to a client's legs