ATI: Leadership NURSING PROCTORED 2016. Contains 194 Most commonly Tested Questions for Last Minute Exam Preparation. See List in description.

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2016 Version: 1. A nurse is ​assessing pressure ulcers​ on four clients to ​evaluate the effectiveness​ of a change in the wound care procedure. Which of the following ​findings indicate w... ound healing. a. Erythema on the skin surrounding a client's wound b. Deep red color on the center of the clients wound c. Inflammation noted on the tissue edges of a client's wound d. Increase in serosanguineous exudate from the clients wound ​(damaged capillaries) Rationale: Leadership 7.0 pg 329: - Stages of Wound Healing - Inflammatory stage - ​beginning stage, also usually suggests ​infection - Begins with the injury and lasts 3 to 6 days - Effects to the wound: controlling bleeding with vasoconstriction and retraction of blood vessels, and with clot formation. Delivering oxygen, WBCs, nutrients to the area via blood supply. Hemostasis occurs along with fibrin formation. Macrophages engulf microorganisms and cellular debris (phagocytosis). - Proliferative stage - Lasts the next 3 to 24 days - Effects to the wound: replacing lost tissue with connective or granulated tissue or collagen. Contracting the wound’s edges. Resurfacing of new epithelial cells. ​Healthy granulation tissue does not bleed easily. Dark granulation tissue can be a sign of infection​, ischemia, or poor perfusion. In the final phase of the proliferative stage of wound healing, epithelial cells resurface the injury. - Maturation or remodeling stage - Occurs after day 21 and involves that strengthening of the collagen scar and restoration of a more normal appearance. It can take more than 1 year to complete, depending on the extent of the original wound. When scar tissues are forming. - Appearance: - Note the color of open wounds. - Red: healthy regeneration of tissue. - Yellow: presence of purulent drainage and slough - Black: presence of eschar that hinders healing and requires removal. 2.​ A nurse received change of shift report at 0700 for four clients. Which of the following actions should the nurse perform ​first​? a. Obtain a breakfast tray for a client who received a morning dose of insulin aspart. ​- (fast-acting insulin...usually takes effect after 15 minutes) b. Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400. c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900 d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours 3.​ A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the ​newly licensed nurse​?a. A client who has multiple sclerosis and ataxia​ - ​(normal finding for someone that has multiple sclerosis = most stable - showed up on online practice tests) b. A client who has brain tumor and is admitted for chemotherapy ​← dead c. A client who has guillain-barre syndrome and a tracheostomy -unstable d. A client who sustained a concussion and is being monitored for complication -unstable 4​. A nurse is providing teaching to a client about ​advance directives​. Which of the following statements by the client indicates an ​understanding ​of the teaching? a. “Once I sign my living will, a family member must co-sign it” b. “I will wait until I have a serious health problems to sign my advance directives” c. “My doctor will need to provide approval for the decisions outlines in my living will d. “My durable power of attorney for health care is part of my advance directives”​-​durable power of will and living will are components of advance directives. Rationale: Leadership 7.0 page 38 5. A nurse is chairing a committee about ​preventing infant abduction​ in a new birth care center. Which of the following ​quality control tasks​ should the nurse assign to be completed ​first? a. Identify the industry standards for infant safety b. Evaluate the selected infant safety system c. Choose an infant safety system d. Establish measurement criteria for infant safety systems 6.​ A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform ​dysphagia screening​ to determine the client's need for a referral to which of the following providers? a. Physical therapist b. Respiratory therapist c. Speech therapist d. Occupational therapist 7​. A home health nurse is assessing the home environment during an initial visit to a client who has a ​history of falls​. Which of the following findings should the nurse identify as ​increasing the client's risk for falls ​(select all that apply) - A wheeled office chair at the client's computer desk - A raised vinyl seat on the toilet in the bathroom - A throw rug covering some cracked vinyl flooring in the kitchen - A folding chair without arm rests. - A two wheeled walker used to assist the client with ambulation 8​. A nurse manager is planning to assign care for four clients on a medical surgical unit. Which of the following clients should the nurse ​assign to a LPN a. An older adult who has lung cancer and has periodic episodes of severe ​dyspnea b. A middle adult client who has a below the knee amputation and requires a dressing change ​- stable; only needs dressing change c. A young adult client who is postoperative,​ receiving morphine via epidural, and reports pruritus d. An adolescent who is new diagnosed with DM and ​requires teaching​ regarding insulin administration9.​ While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives​. Which of the following is the ​priority for the nurse to take? a. Remind nurses to obtain this information during the admission processb. Reinforce the potential consequences of not having his information on record to the nursing staff c. Meet with nursing staff to review the policy regarding advance directive d. Ask nurse who are caring for client without his information in the medical record to obtain it 10​. A nurse is caring for a group of clients. Which of the following should the nurse ​see first​? a. A client who is postoperative and his a fever. b. A client whose pressure ulcer has serosanguineous drainage on the dressing-normal c. A client who has diabetes mellitus and is diaphoretic- ​hypoglycemia d. A client who has a fractured hip and reports a pain level of 7 on a scale from 0 to 10.-no Rationale:Hypoglycemia may lead to SZ, coma or death if it’s not treated right away. Other S/S: Tachycardia, cold sweats, irritability, confusion, and diaphoretic aka sweating. 11​. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse care for ​first​? a. A client who is 4 hr post-operative following a hernia repair and has ​pitting​ edema of the right leg b. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea c. A client who has pneumonia and requires a tracheostomy dressing change d. A client who has a new colostomy and requires discharge teaching 12​. A nurse manager discovers there is a ​conflict between nurses​ working the day shift and nurses working on the night shift. Which of the following actions should the nurse manager take ​first? a. Acknowledge the conflict and encourage the nurses to focus on working as a team. b. Gather information regarding the situation c. Encourage the nurses to resolve the conflict autonomously d. Meet with a committee from each shift to discuss issues related to the conflict 13​. A nurse in an urgent care clinic is admitting a client who has been exposed to a ​liquid chemical​ in an industrial setting. Which of the following actions should the nurse take ​first​? a. Don personal protective equipment ​- protect yourself first b. Irrigate the exposed area with water c. Remove the client’s clothing d. Report the incident to OSHA 14​. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform ​first? a. Complete an incident report b. Measure the client’s vital signs c. Inform the nurse manager d. Call the provider 15​. A nurse is assessing a client who has ​meningitis​. Which of the following findings should the nurse report to the provider immediately?a. Decreased level of consciousness​ - ​getting sleepier..neurological damage? Maybe? ​I liike disss, baka INC ICP b. Generalized rash over trunk c. Increased temperature d. Report of photophobia Rationale:​Seek immediate medical care if you or someone in your family has meningitis symptoms, such as: ● Fever. ● Severe, unrelenting headache. ● Confusion. ● Vomiting. ● Stiff neck. 16.​ A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report ​ with regard to the care pathway? a. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.​???? b. A blood culture was obtained after antibiotic therapy had been initiated c. An allergy to penicillin required an alternative antibiotic to be prescribed ​HMM d. The route of antibiotic therapy on the care pathway was changed from IV to PO A ​variance report​ should be initiated whenever an error is made involving a client, even if no injury occurred. 17​. A nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager​ assign to a float nurse​ from the medical-surgical unit? a. A client who is postterm and is receiving oxytocin for labor induction b. A client who gave birth to her first child and requires instruction on breastfeeding techniques c. A client who is 2 days post-operative following a caesarean birth and is having difficulty ambulating. ​- most stable d. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion 18​. A nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of ​methicillin-resistant Staphylococcus aureus​ (MRSA). Which of the following members of the interprofessional team should the nurse consult? a. Risk management coordinator b. Clinical pharmacist c. Nursing supervisor d. Infection control nurse 19​. A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the ​client tells the nurse that the surgery is not an option​. Which of the following is an appropriate action ​for the nurse to take? a. Discuss with the client her concerns regarding the procedure b. Provide the client with information on treatment options and outcomes c. Inform the client of the consequences of uterine prolapse and the need for intervention d. Initiate a mental health consult to determine the client’s reasons for refusing surgery20​. A nurse in the emergency department is assessing a client who is ​unconscious​ following a motor-vehicle crash. The client ​requires immediate surgery​. Which of the following actions should the nurse take? a. Delay the surgery until the nurse can obtain informed consent b. Obtain telephone consent from the facility administrator before the surgery c. Ask the anesthesiologist to sign the consent d. Transport the client to the operating room without verifying informed consent 21​. A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to ​delegate to an assistive personnel​? a. Performing postmortem care prior to transferring the client to the morgue b. Advising a client on self-administration of acetaminophen c. Teaching a client to perform a finger-stick for testing blood glucose levels d. Informing a family of a client’s progress in physical therapy 22. A nurse is working on a quality improvement team that is ​assessing an increase in client falls​ at the facility. ​After problem identification​, which of the following actions should the nurse plan to ​take first​ as part of the​ quality improvement process? a. Notify staff of the increased fall rate b. Review current literature regarding client falls c. Implement a fall prevention plan d. Identify clients who are at risk for falls 23​. A nurse is completing a performance evaluation for an assistive personnel (AP). Which of the following actions by the AP ​requires intervention​ by the nurse? a. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile ​. b. The AP closes the door of a client who is on airborne precautions c. The AP removes cut flowers from the room of a client who is in a protective environment. d. The AP wears a mask when caring for a client who has varicella Rationale: ​Alcohol-based ​hand sanitizers​ are highly effective against non–spore-forming organisms, but they do​ not ​kill C​. ​difficile​ spores or remove ​C​. ​difficile​ from the ​hands 24​. A charge nurse notices that staff nurses are ​having difficulty using new IV infusion pumps​ for medication administration. Which of the following is the ​priority action​ by the charge nurse? a. Asses the staff nurses’ knowledge deficit ​ ​- assess first b. Pair an inexperienced nurse with an experienced nurse c. Demonstrate use of the pump during medication administration d. Plan an in-service education program on the unit 25​. A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which of the following tasks should the nurse ​assign to the AP​? a. Administer the initial bolus feeding to a client who has an NG tube → admin of med b. Check a client’s pain level 30 min after receiving acetaminophen → assessment of pain c. Collect a urine specimen from a newly admitted clien​t d. Instruct a client to splint an abdominal incision → considered teaching/assessment 26​. A nurse is assisting with triage during a mass casualty event. The nurse applies a ​red tag​ to a client. Which of the following actions should the nurse take?a. Treat the client’s injuries within 30 min b. Provide treatment for life-threatening injuries c. Provide treatment for minor injuries d. Allow the client to die without further intervention BLACK Red tags​ - (immediate) are used to label those who cannot survive without immediate treatment but who have a chance of survival. ​Yellow tags​ - (observation) for those who require observation (and possible later re-triage). Their condition is stable for the moment and, they are not in immediate danger of death. These victims will still need hospital care and would be treated immediately under normal circumstances. ​Green tags​ - (wait) are reserved for the "​walking​ wounded" who will need medical care at some point, after more critical injuries have been treated. ​White tags​ - (dismiss) are given to those with minor injuries for whom a doctor's care is not required. ​Black tags​ - (expectant) are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available. 27​. A home health nurse is performing a safety assessment of a client’s home. Which of the following findings should the nurse identify as a ​safety hazard​? a. The client has used tacks to secure the carpet on the stairs X b. The client’s electrical cord is taped to the floor X c. The client's bedside lamp is plugged in using an extension cord with two prongs d. The client stores cleaning supplies in a locked cabinet above his head X 28​. A charge nurse is observing a newly licensed nurse provide care for a client who has ​Clostridium difficile infections. Which of the following actions by the newly licensed nurse indicate an ​understanding of proper infection control procedures​? A. Applies a mask before entering the client’s room B. Removes fresh flowers from the client’s room. C. Washes her hands with an alcohol-based hand rub after caring for the client. D. Wears a gown when caring for the client Rationale: C-diff is considered Contact Isolation 29​. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client’s need for which of the following supplies to manage tracheostomy at home? (Select all that apply.) A. Pipe cleaners B​. O2 Tank C. Cotton balls D. Petroleum Jelly E. Obturator30​. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients ​can give informed consent​? A. An adult client who has ​alcohol intoxication B. ​An adolescent client who is legally emancipated C. An older adult client who ​has questions​ about the procedure D. An adult client who has moderate ​Alzheimer’s disease. Rationale: The form for informed consent must be signed by a competent adult. Emancipated minors (minors who are independent from their parents, such as a married minor) can provide informed consent for themselves. 31​. A nurse is discussing the ​safekeeping of valuables​ with a client who is scheduled for surgery. Which of the following client statements indicates the ​need for further teaching​? a. “I can wear my ankle bracelet since i am just having a local anesthetic: ​maybe this? b. “I can leave my wedding ring on if it is taped in place” c. “I should remove my dentures before the procedure” d. “I should leave my valuables with a family member” 32​. A nurse is caring for an older adult client who has ​Stage III pressure ulcer.​ The nurse requests a consultation with the wound care specialist​. Which of the following actions by the nurse is appropriate when working with a consultant? a. Request the consultation after several wound care treatments are tried b. Arrange for the wound care nurse specialist to see the client daily to provide the recommended treatments c. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation d. Provide the consultant with subjective opinions and beliefs about the client’s wound care 33​. A nurse is observing an AP administer 0.9% sodium chloride enema to an adult client. For which of the following ​actions by the AP should the nurse intervene​? a. Positions the client on her left side with knees flexed b. Administers the solution at room temp - ​ok c. Points tubing in the ​direction of the umbilicus​ during insertion - ​ok d. Inserts the tubing 8cm (3.1 in) into the rectum -​ok ​insert 3-4 inches Rationale: ​sims position: left side, right leg flexed, left leg ​straight http://www.atitesting.com/ati_next_gen/skillsmodules/content/enemas/viewing/cleansing_enemas. html 34​. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an ​understanding of the teaching? a. “I should encrypt personal health information when sending emails.”​ ​→ ​Encryption is a way to make data unreadable at rest and during transmission. b. “I can post the client’s vital signs in the client’s room.” c. “I can use another nurse’s password as long as i log off after using the computer” d. “I should discard personal health information documents in the trash before leaving the unit”35​. A nurse is participating on a committee that is considering the creation of a policy that will allow the nurses to remove chest tubes. Which of the following is an ​appropriate resource for the nurse to consult in planning for this policy​? a. ANA Standards of Practice b. ANA Code of Ethics c. State nurse practice act​ - ​showed up on practice tests d. Institute of medicine 36​. A charge nurse observe a licensed practical nurse tell a client that she will ​return with a medication​ to help relieve the client’s nausea. The LPN does not return with the medication. The charge nurse should reinforce which of the following ​ethical principles​ with the LPN? a. Veracity b. Justice c. Fidelity d. Nonmaleficence Rationale: Review ATI pg. 47 Autonomy​: ​The ability of the client to make personal​ ​decisions, even when those decisions might not be in the client’s own best interest ●●​ ​Beneficence​: ​Care that is in the best interest of​ ​the client ●● ​Fidelity​: ​Keeping one’s promise to the client about care​ ​that was offered ●●​ ​Justice​: ​Fair treatment in matters related to physical​ ​and psychosocial care and use of resources ●● ​Nonmaleficence​: ​The nurse’s obligation to avoid causing​ ​harm to the client ●● ​Veracity​: ​The nurse’s duty to tell the truth 37. ​A nurse administrator is using ​benchmarking​ as control criteria while ​reviewing current policies and procedures​. Which of the following actions should the nurse take? a. Use root cause analysis to identify gaps in meeting standards​ - If benchmark is ​NOT​ met, do dis hoe b. Establish work initiatives to promote a positive environment c. Compare practices within the facility against other high-performing facilities d. Determine how current practice will affect future performance within the facility Benchmarks are goals that are set to determine at what level the outcome indicators should be met. Data is collected, analyzed, and compared with the ​established benchmark. ●● ​If the benchmark is not met​, possible influencing factors are determined. A root cause analysis can be done to critically assess all factors that influence the issue. A root cause analysis: ◯◯ Focuses on variables that surround the consequence of an action or occurrence. ◯◯ Is commonly done for sentinel events (client death, client care resulting in serious physical injury) but can also be done as part of the quality improvement process. ◯◯ Investigates the consequence and possible causes. ◯◯ Analyzes the possible causes and relationships that can exist. ◯◯ Determines additional influences at each level of relationship. ◯◯ Determines the root cause or causes. 38​. A nurse enters a client’s room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take ​first​? a. Place a faulty equipment tag on the pump b. Notify the providerc. Auscultate the client’s lungs d. Complete an incident report 39​. A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an ​appropriate nursing response​? a. “It’s not too late to cancel the surgery if you want to” b. “Why did you make the decision to have this procedure?” c. “This won’t take long and it will be over before you know it” d. “You shouldn’t be worried because the procedure is very safe” 40​. A facility infection control nurse is reviewing the reports of a group of clients. Which of the following infections should the nurse ​report to the public health department? a. Lyme disease b. Bacterial conjunctivitis c. Health care-acquired pneumonia d. Methicillin-resistant Staphylococcus aureus Rationale: ​http://www.health.ri.gov/diseases/infectious/resultsreportable.php 41​. A nurse on a surgical unit is preparing to ​transfer a client to a rehabilitation facility​. Which of the following information should the nurse include in the ​change-of-shift report​? a. The steps to follow when providing wound care ​-​ orders​ included in paperwork transferred with patient to facility b. The client’s preferred time for bathing ​- who you think you is c. The belief that the client has a difficult relationship with his son d. The time the client received his last dose of pain medication​ ​- the only relevant information at the time of transfer - also showed up on practice tests 42​. A nurse receives a new prescription over the telephone from a client’s provider. Which of the following actions should the nurse take ​first a. Write down the complete prescription b. Read back the prescription to the provider​ - ​verification c. Document the prescription as a telephone prescription in the medical record d. Ensure that the provider signs the prescription 43.​ A charge nurse witnessed an assistive personnel ​failing to follow facility protocol ​when discarding contaminated linens. Which of the following actions should the nurse take ​first​? a. Discuss the issue with the AP b. Notify the unit manager about the incident c. Reinforce facility protocols at the next staff meeting d. Alert the infection control department 44​. A nurse is planning care for a client who is ​disoriented and has a history of wandering​. Which of the following actions should the nurse include in the plan? a. Raise all four side rails on the client’s bed ​- never raise all 4 side rails up - considered a restraint b. Remove the clock and calendar from the client’s room→ reorient client c. Obtain a prescription for a sedative for the client→ chemical sedations . ​less invasive first; meds always last resort and if patient is causing harm to him/herself only d. Provide distractions for the client during the day45.​ A n​urse is caring for a client who has a new diagnosis of chlamydia​. Which of the following actions should the nurse take? a. Initiate contact precautions​ → ​Chlamydia is an STI...​SEXUALLY TRANSMITTED ​← ​maybe they tryna have sex with gloves and gown hahah b. Report the infection to the local health department ​?? - nationally reportable c. Apply an antiviral cream to lesions - ​Topical antibiotic therapy alone is inadequate for treatment of chlamydial infection and unnecessary when systemic treatment is administered. d. Instruct the client to use condoms until the treatment is completed → ​avoid sex while undergoing treatment ooi 46. ​A nurse is teaching a class of newly licensed nurses about evidence-based practices. The nurse should include which of the following as the ​first step in evidence-based practice​? a. Apply research to client care practice → 4th b. Develop a clinical question​ 1 c. Critically assess the evidence 3 d. Collect evidence from a variety of sources 2 Rationale: 5 steps of Evidence Based Practice Ask a question Converting the need for information (about prevention, diagnosis, prognosis, therapy, causation, etc) into an answerable question Find information/evidence to answer question Tracking down the best evidence with which to answer that question Critically appraise the information/evidence Critically appraising that evidence for its validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice) Integrate appraised evidence with own clinical expertise and patient’s preferences Integrating the critical appraisal with our clinical expertise and with our patient's unique biology, values and circumstances Evaluate Evaluating our effectiveness and efficiency in executing Steps 1-4 and seeking ways to improve them both for next time 47​. A nurse assumes the leading role on the hazardous materials team immediately following a chemical mass casualty incident in the community. As clients arrive at the designed triage area outside the hospital, which of the following actions should the nurse take? a. Place shower caps over the client's’ hairb. Remove contaminated clothing​- ​p.102 undress the client and remove all identifiable particulate matter c. Scrub the client’s skin with betadine solution-clean skin with water d. Admit the injured clients to positive-pressure rooms 48​. A case manager is reviewing documentation on several clients and notes a ​progress report that falsely identifies a client as HIV-positive due to multiple sexual partners​. The nurse manager should identify that which of the following torts has occurred? a. Libel b. Negligence c. Battery d. Slander Rationale: ​False communication or communication with careless disregard for the truth with the intent to injure an individual’s reputation. ◯◯ ​Libel: ​Defamation with the ​written word ​or photographs (a nurse documents in a client’s health record that a provider is incompetent). ◯◯ ​Slander​: ​Defamation with the ​spoken​ word (a nurse tells a coworker that she believes a client has been unfaithful to the spouse). 49.​ A nurse is preparing to complete morning assignments on several assigned clients. Which of the following clients should the nurse plan to ​assess first​? a. A client who had a bladder scan that indicated 250 mL of urine in the bladder ​normal capacity between​ 400-600.​ 1st need to void at​ 150mL,​ urge to void at ​300​. OK b. A client who is 3 days postoperative and who’s dressing has serosanguinous drainage c. A client who has diabetes and an early morning blood glucose of 220 mg/dL d. A client who has a nasogastric tube to intermittent suction and reports nausea Rationale:​ patient may complain of nausea if tube is not patent... 50​. A charge nurse overhears a staff nurse discussing a client’s diagnosis in the cafeteria. Which of the following responses should the charge nurse make? a. “Please stop discussing the client in a public area” b. “Do you understand the HIPPA regulations?” c. “We should discuss your concerns with the client’s care team” d. “I will notify the client’s provider about this breach of confidentiality 51​. A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as ​maintaining sterile technique​? A. Places sterile gauze 1.3cm (0.5 in) away from the edge of a sterile drape B. Uses sterile forceps to pack sterile gauze into the wound C. Sets up the sterile field 30min prior to performing the dressing change D. Uses a sterile-gloved hand to adjust the back of the sterile gown.52​. A nurse working in a long term care facility is assessing an older adult client who has been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the following actions should the nurse take? A. Place the client in a negative-pressure airflow room B. Perform hand hygiene with alcohol based hand sanitizer. C. Clean the equipment in the client’s room with bleach. ​could be C. diff due to the regular use of antibiotics - kills normal flora - chronic use of antibiotics can lead to it. D. Initiate droplet precautions for the client. 53​. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is having t​rouble focusing and has difficulty completing care​ for his assigned clients. Which of the following interventions is appropriate? A. Advise him to complete the less time consuming tasks first. B. Recommend that he take time to plan at the beginning of his shifts. C. Offer to provide care for his clients while he take a break. D. Ask other a staff members to take over some of his tasks. 54​. A nurse is planning discharge for a client who has lung resection. The nurse initiates a ​referral for a ​social worker​. ​Which of the following assessment data supports this referral? A. The client needs to have someone bring O2 tanks and equipment to her home. - ​case manager? B. The client needs to have range-of-motion exercises to assist with ambulation - ​PT C. The client needs to arrange financial resources to purchase equipment. D. The client needs to have someone come in to help her bathe at home. - ​Home health aide 55.​ A nurse initiates a r​eferral to an occupation therapist​ for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for this referral? A. The client reports pain when chewing solid foods. - speech therapist B. The client expresses the desire to join a support group. C. The client requires assistance with completing oral hygiene. D. The client has difficulty ambulating with a walker. (physical therapist?) - yes Rationale: Occupation Therapist promotes or improves person’s ability to do ADL’s. 56​. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client’s care? (Select all that apply) A. Nutritional therapists B. Case Manager C. Mental Health counselor D. Occupational therapist E. Physical therapist57​. A nurse is prioritizing care after a receiving change-of-shift report on a four clients. Which of the following clients should the nurse ​assess first​? A. A client who reports a headache with sensitivity to light. B. A client who reports feeling lightheaded when he stands up from a lying position C. A client who reports indigestion and pain in her jaw ​- s/sx heart attack D. A client who reports an urge to void but has not urinated during the prior shift Rationale: Pg 6 Third: Circulation. Identify circulation concern (hypotension, dysrhythmia, inadequate cardiac output,compartment syndrome). 58​. A nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority​? A. A client who has depressive disorder and has poor personal hygiene B. A client who has dementia and exhibits aphasia C. A client who has bipolar disorder and displays constant pacing D. A client who has schizophrenia and uses neologisms Rationale: Pg 77 (mental ati) Complication: Physical exhaustion and possible death: A client in a true manic state usually will not stop moving, and does not eat, drink, or sleep. This can become a medical emergency. 59​. A nurse is planning care for a group of clients. Which of the following action should the nurse take ​first​? A. Obtain a breakfast tray for a client whose total parenteral nutrition was discontinued 4 hrs ago. B. Auscultate the bowel sounds of a client who has not had bowel movement after taking a laxative 12hr ago. C. Provide instruction to the caregiver of a client who has dementia and new diagnosis of diabetes mellitus. D. Check a client who has a leg cast and reports a ​new onset​ of pain. 60.​ A nurse on a med surg unit is caring for a client who asks about ​advance directives​ and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make? A. “You must choose a member of your family to serve as a your health care proxy.” B. “ A health care proxy can make decisions for you when you are unable to do so.” C. “You should appoint a health care proxy before undergoing an invasive procedure.” D. “It is necessary for an attorney to approve your health care proxy.” Rationale: A durable power of attorney for health care/health care proxy is a legal document that designates a health care surrogate, who is an individual authorized to make healthcare decisions for a client who is unable. 61. A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two of the medications, stating, “I’ve never taken these before.”. Which of the following actions should the nurse take first? A. Consult the pharmacist about the client’s prescribed medications. B. Compare the client’s medication administration record with the prescriptions on the transfer orders.C. Review the intended purpose of the prescribed medication with the client. D. Call the provider to clarify the clients prescribed medications. 62. A nurse on a med surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? A. A client who is postoperative following laminectomy 12hrs ago is unable to void B. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy C. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot D. A client who has methicillin-resistant Staphylococcus aureus *MRSA) and has an axillary temperature of 38C (101F) 63. A nurse in the emergency department admits a client who has been exposed to ​cutaneous anthrax​. Which of the following actions should the nurse take? A. Plan to administer an antiviral medication to the client. B. Wear an N95 respirator mask while caring for the client. C. Prepare to administer antibiotics to the client. D. Place a surgical mask on the client during transfer to the unit. I mean its not transmitted person to person, not droplet or airborne 64. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take ​first? A. Discuss the time management strategies with the nurses B. Review facility policies for taking scheduled breaks. C. Provide coverage for the nurses’ breaks D. Determine the reasons the nurses are not taking scheduled breaks. 65. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? A. False imprisonment B. Libel C. Assault D. Battery 66. A nurse is speaking with a visitor who asks a questions about the status of a relative who is a client on the unit. Which of the following responses by the nurse is appropriate? A. “Im not taking care of your relative today, so I don’t have the latest information” B. “ I will have your relative’s nurse come and talk with you about her care.” C. “Let me check your relative’s medical record to see how she’s doing.” D. “Please ask your relative about this, because I cannot share information about her.”67. A nurse suggests respite care for the partner of a client who has mild cognitive impairment. The client’s partner asks the nurse how that would help. The nurse should explain the respite care would do which of the following? A. Allow her to take time off from attending to her partner B. Provide volunteers who will run errands for her. C. Send a clinician to assess the safety of leaving her partner alone D. Help her arrange transferring her partner to an assisted living facility. 68. A charge nurse ​observes a client fall​ during ambulation and notes that his ​gait belt was not in place​. In reviewing the incident report, the nurse finds ​no mention of a gait belt.​ ​Which of the following ethical principles ​should guide ​the nurse’s ​subsequent actions​? A. Non maleficence B. Veracity C. Fidelity D. Beneficence 69. A nurse is caring for a client who is scheduled for ​placement of a central venous access device. ​Which of the following actions is the​ nurse’s responsibility​ in the ​informed consent process? A. Place a photocopy of the signed consent in the client’s medical record B. Review the risks and benefit of the procedure with the client C. Discuss alternative treatment options with the client D. Assess the client’s understanding after the provider has talked with her. 70. A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching? A. Remove the client’s restraints every 2 hr. B. Allow 1 fingerbreadth between the restraint and the client’s wrists ​Dos! C. Attach the restraints to the fixed portion of the frame of the client’s bed. ​Moveable part! D. Secure the client’s restrains with a square knot. ​Quick release knot betch SCREENSHOT VERSION: 2016 1. A nurse is ​preparing​ an educational program for staff members 2 a new intravenous pump. ​Identify the sequence of actions​ the nurse should taken when ​developing the program​.​ (Move the steps into the box on the right, placing them in order of performance). - Determine​ what ​skills​ ​to teach the staff members. - 1 - Develop ​learning objectives​ ​for the program. - 2 - Identify resources​ available to meet objectives. - 3 - Review the staff member's’ evaluation of the program. - 42. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take ​first​. a. Inform the unit manager of the incident. b. Speak with the AP about the incident. c. Review the chart for non-restraint alternatives for agitation. d. Remove the restraints from the client’s wrists. ​- ​patient safety first - remove it right away since there’s no order 3. A​ nurse is participating in the ​development of a disaster management plan​ for a hospital. The nurse should recognize that which of the following resources is the ​highest priority ​to have available ​in response to a bioterrorism event​? a. A sufficient supply of personal protective equipment b. A system for tracking client information c. A mental health specialist on the response team d. A network for communication between staff members and families Rationale: ​page 62:​ ​Bioterrorism​ is the dissemination of ​harmful toxins, bacteria, viruses, or pathogens​ for the purpose of causing illness of death. Nurse and other health professionals must be prepared to respond to an attack by being proficient in early detection, recognizing the causative agent, identifying the affected community, and providing early treatment to affected people. ​Need sufficient supply of personal protective equipment or else others will get infected with either anthrax, smallpox, plague, etc. Participate in planning and preparation for immediate response to a bioterrorist event; Identify potential biological agents for bioterrorism; Survey for and report bioterrorist activity (usually to the local health department); Promptly participate in measures to contain and control the spread of infections resulting from bioterrorist activity. 4. Not there ​- oookkkkkk 5. A parish nurse is ​making a referral to a community meal delivery program​ for a member of the congregation. This is an ​example of which of the following functions​ of the parish nurse? a. Health educator b. Liaison c. Pastoral care provider d. Personal health counselor Rationale:​ ​Community ATI page 38​: ​parish nurses​ ​promote the health and wellness of populations of faith communities​. The population often includes church members and individuals and groups in the geographical community. They work closely with pastoral care staff, professional health care members, and lay volunteers to provide a holistic approach to healing (body, mind, and spirit). Functions: - Personal health counseling (health-risk appraisals, spiritual assessments, support for numerous acute and chronic; actual and potential health problems) - Liaison between faith community and local resources - Facilitates support groups - Spiritual support (help identify spiritual strengths for coping).6. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls​. Which of the following findings should the nurse identify as ​increasing the client’s risk of falls.​ (Select all that apply.) a. A throw rug covering some cracked vinyl flooring in the client’s kitchen b. Folding chairs around the kitchen table c. A two-wheeled walker to assist the client with ambulation d. A raised vinyl seat on the toilet in the client’s bathroom e. A wheeled office chair at the client’s computer desk Rationale​: ​Leadership (7.0, new version) pg 56​ and http://www.elderissues.com/library/?fuseaction=article&art_id=152 - avoid using full side bed rails for client who get out of bed or attempt to get out of bed bed without assistance. - Provide the client with nonskid footwear - Keep the floor free from clutter with a clear path to the bathroom (no scatter rugs, cords, furniture). - Ensure adequate lighting - Keep assistive devices (glasses, walker, transfer devices) nearby after validation of safe use by the client and family. - Educate the client and family/caregivers on identified risks and the plan of care. - Lock wheels on beds, wheelchairs, and carts to prevent the device from rolling during transfers or stops. - Use chairs or bed sensors to alert staff of independent ambulation for clients at risk of getting up unattended. 7. A nurse suggest ​respite care​ for the partner of a client who has ​mild impairment​. The client’s partner asks the nurse how that would help. The nurse should explain that ​respite care​ would do which of the following? a. Allow her to take time off attending to her partner. b. Send a clinician to assess the safety of leaving her partner alone. c. Help her arrange transferring her partner to an assisted living facility. d. Provide volunteers who will run errands for her. Rationale: http://www.aarp.org/relationships/caregiving-resource-center/info-08-2010/pc-respite-care-a-bre ak-for-the-caregiver.html - Respite care​ is temporary institutional care of dependent elderly, ill, or handicapped person, providing ​relief or rest ​for their usual caregivers. 8. A ​case manager​ observes a ​family member​ of a client who has ​Alzheimer’s disease ​throwing books on the floor and sobbing while the client is having a diagnostic test. Which of the following actions should the case manager take ​first​? a. Refer the caregiver to a local support group. b. Help the caregiver arrange for respite care. c. Offer to have a brief talk with the caregiver. d. Consult social services to explore counseling. Rationale:​ talk to them first to assess and then refer them.9. A nurse is preparing to ​transcribe​ a client’s medication prescription in the medical record. Which of the following should the nurse recognize as containing the ​essential components ​of a ​medication order​? a. Aspirin 650 mg by mouth every 4 hr ​- med name, dose, route, time b. NPH insulin 10 units before meals and at bedtime ​- no route c. Multivitamin every morning by mouth ​- no dose d. Haloperidol 1 mg by mouth ​- no time Rationale: ​Meds, Dose, Route, Time​, → needs to be considered on medication order. http://www.atitesting.com/ati_next_gen/skillsmodules/content/medication-administration-1/equip ment/orders.html - 10. 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 licensed practical nurse​? ​REPEAT a. An adolescent client who is ​newly diagnosed​ with diabetes and ​requires teaching ​regarding insulin administration b. A young adult client who is postoperative, receiving morphine via ​epidural​, and reports pruritus c. A middle adult client who had a below-the-knee amputation and requires a dressing change d. An older adult client who has ​lung cancer ​and has periodic episodes of ​severe dyspnea Rationale:​ ​Leadership 6.0 (2013 version) pg 12: - Nurses can only delegate tasks appropriate for the skill and education level of the health care provider who is receiving the assignment - RNs ​cannot delegate​ the nursing process, client education, or tasks that require clinical judgement to LPNs or AP. 11. A ​charge nurse​ is receiving ​change-of-shift report​. Which of the following situations should the charge nurse address​ first​? a. The emergency department is waiting to give report on a new admission b. A nurse on the previous shift wrote an incident report about a medication error c. Transport assistance is unavailable to take a client to occupational therapy d. Two staff members have called to say they will be absent - Rationale: Although it is from the previous shift, still need to continue on monitoring 12. A nurse is caring for a client who has ​early stage ​Alzheimer’s disease​. In which of the following actions is the nurse acting as a ​client advocate​? a. Requesting a referral for the client to attend reminiscent therapy sessions b. Reorienting the client several times throughout the day c. Performing an updated cognitive assessment on the client d. Providing assistance for the client when ambulating down the hall Rationale: ​https://www.ncbi.nlm.nih.gov/pubmed/15846613 - Reminiscence Therapy ​(RT) involves the ​discussion of past activities​, events and experiences with another person or group of people, usually with the aid of tangible prompts such as photographs, household and other familiar items from the past, music and archive sound recordings13. 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. Return unused supplies from the bedside to the unit’s supply stock. c. Wait to dispose of sharps containers until they are completely full. d. Store opened bottles of normal saline in a refrigerator for up to 48 hr. Rationale:​ ​Leadership 7.0 pg 18: - Cost containment: strategies that promote efficient and competent client care while also producing needed revenues for the continued productivity of the organization. - Example: returning uncontaminated, unused equipment to the appropriate department for credit 14. A nurse working on a medical-surgical unit is receiving shift report regarding four clients. Which of the following clients should the nurse see ​first​? a. A 50-year-old client reporting abdominal pain of 7 on a scale of 0 to 10 b. An 80-year-old client who has a urinary tract infection and a temperature of 39.2 C (100.8 F) c. A 75-year-old client who has pneumonia and has an O2 saturation of 92% d. A 45-year-old client who has​ new onset ​of confusion 24 hr after a total hip arthroplasty. Rationale: Leadership 7.0 page 5-6: - ABC framework - Circulation is necessary for oxygenated blood to reach the body’s tissue 15. A nurse manager is reviewing the ​nursing code of ethics​ with the staff nurses. Which of the following statements by a staff nurse indicate ​understanding of the teaching​ (Select all that apply). a. “The family of a newly admitted client recently treated me to lunch in the hospital cafeteria.” b. “I will attend continuing education classes for professional growth.” c. “I can delegate the removal of an IV catheter to an LPN on the unit.” d. “I administer pain medication to my clients even if they have a history of narcotic addiction.” e. “I have the assistive personnel double-check packed RBCs when other nurses are busy.” Rationale:​ ​http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html - A LPN can d/c an IV line but, not a PICC, or anything higher rated than that. 16. A nurse is discussing advance directives with a client. Which of the following statements by the client indicates an ​understanding​ of ​advance directives? a. “I know I have the right to determine if I remain on a breathing machine.” b. “I know I’ll need a lawyer to change them later, so I want to get them right.” c. “By naming a health care proxy, I give up the right to make my own medical decisions.” d. “I trust my doctor, so I’m going to leave it to him to do what’s best for me.” Rationale​:​ Leadership (7.0) page 38-39 - To communicate a client’s wishes regarding end-of-life care should the client become unable to do so. 17. 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. Document a factual description of the situation b. Remove the nurse from the unit ​- patient’s safety firstc. Have a blood alcohol level drawn from the nurse d. Report the situation to the director of nursing Rationale:​ It would be the first thing the nurse manager would do. 18. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing​ and ​has difficulty completing care​ for his assigned clients. Which of the following interventions is appropriate? a. Recommend that he take time to plan at the beginning of his shift b. Advise him to complete less time-consuming tasks first c. Ask other staff members to take over some of his tasks d. Offer to provide care for his clients while he takes a break Rationale: Leadership (7.0) pg 10: - Orientation helps newly licensed nurses translate the knowledge, skills, and attitudes learned in nursing school into practice. - TIME MANAGEMENT; ATI Practice B 19. 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? REPEAT a. A client who gave birth to her first child and required instruction on breastfeeding techniques b. A client who is 2 days post-operative following a caesarean birth and is having difficulty ambulating c. A client who is postterm and is receiving oxytocin for labor induction d. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion Rationale: ​A med-surg nurse can help this patient. The other choices require a nurse who knows a great deal of OB to help these patients. 20. 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 windows of the client’s room are open. b. The client is covered with a woolen blanket. c. The oxygen machine has grounded plug. d. The family keeps a spare oxygen tank in the room. Rationale: wool causes sparks. 21. A nurse is caring for a client who has a pressure ulcer on the coccyx. Which of the following findings indicated the ​need for referral ​to a wound care specialist? a. Minimal signs of induration at the wound edges b. Presence of granulated tissue over the wound c. Presence of slough in the wound bed d. Epithelialization noted in areas of tissue loss Rationale:​ Tissue types – Assess characteristics, amount (document in percentage) &location - Necrotic Tissue – dead; non-viable i. 1) Slough – yellow, green, grey, nonviable (necrotic) tissue, usually lighter in color, thin, wet stringy. Can be mistaken for a tendon bc of the yellowish color. Debridement is necessary to stage the wound.ii. 2) Eschar – black, brown, dry, nonviable (necrotic) tissue, usually darker in color, thicker, hard - Epithelial tissue​ – deep pink to pearly pink, light purple from edges in full thickness wounds or may form islands in superficial wounds - Granulation tissue​ – ​beefy red, puffy or mounded​ bubbly appearance - Hypergranulation tissue​ – granulation tissue forms above the surface of the surrounding epithelium. Delays epithelialization. 22. A nurse on a medical-surgical unit delegating client care. Which of the following tasks should the nurse ​delegate to an assistive personnel​? a. Instructing a client on self-administration of a tap water enema b. Using a pain rating scale to monitor a client’s pain level ​- assessment - RN role c. Suctioning a client’s long-term tracheostomy ​- on practice tests; says AP can suction. I think key word here is long-term - patient had it for a long time so AP can suction since it’s a norm...i’m talking too much, ok i shut up now​ LOL d. Performing a dressing change on a client’s peripherally inserted central catheter 23. A nurse is providing teaching about ​infection control measures​ to a client who has an ​indwelling urinary catheter​. Which of the following instructions should the nurse include in the teaching? a. Clean the end of the tubing with soap and water before reconnecting it. b. Allow urine to pool in the tubing at night c. Use sterile technique to collect specimens from the drainage system. d. Empty the drainage bag every 12 hr. ​(6 hours) Rationale: Fundamentals 7.0: pg 245 - Specimen collection: sterile for specimens from a catheter. Obtain a sterile specimen from a straight or indwelling catheter using surgical asepsis (sterile technique) 24. 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 appropriate action by the nurse? a. Obtain a provider’s prescription for a blood alcohol level. b. Tell the client that a catheter will be inserted c. Assess the client for urinary retention d. Document the client’s refusal in the chart Rationale: Leadership 7.0 page 35 - Refusal of treatment - All clients must be informed of their right to accept or refuse care. - Competent adults have the right to refuse treatment. The client is asked to sign a document indicating that he understands the risk involved with refusing the procedure or treatment, and that he has chose to refuse it. - Nurse carefully documents the information that was provided to the client and that notification of the provider occurred. 25. A nurse manager is preparing an inservice for a group of staff nurses about ​organ donation. ​Which of the following information should the manager include? a. Organ donation alters the appearance of the body for funeral-related viewing b. Nurses caring for clients at the time of death may request organ donation c. The donor’s family will incur costs related to harvesting the anatomical giftd. Nurses may witness the signing of organ donation consents. Rationale:​ ​The nurse’s job is to reinforce explanations throughout the organ retrieval process. The family must know who legally can give final consent, what options there are for organ or tissue donation, and how donation will affect burial or cremation. Any nurse who could be working in this capacity should review their state’s organ retrieval laws and institutional policies and procedures regarding the final consent process. http://www.rncentral.com/blog/2012/the-nurses-role-in-organ-donation/ Leadership 7.0: pg 46: Nurse are responsible for answering questions regarding the donation process and for providing emotional support to family members. 26. 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. “This won’t take long and it will be over before you know it.” ​← sounds like rape b. “It’s not too late to cancel the surgery if you want to.” c. “Why did you make the decision to have this procedure?” d. “You shouldn’t be worried because the procedure is very safe.” Rationale​: don’t ask why! & rape is def out of the question! 27. A charge nurse is observing a newly licensed nurse insert an ​NG tube​ and connect it to a suction source. Which of the following actions by the newly licensed nurse demonstrates an ​understanding of the process​? a. Inserts an 8-French NG tube b. Dons sterile gloves for the insertion procedure - no; clean gloves c. Clamps the air vent tubing d. Sets the suction to 90 mmHg- 120mmHg intermittent Rationale:​ Fundamentals 7.0 pg 322: Clamp the NG tube, or connect it to the suction device. 28. A nurse administrator is using benchmarking as a control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take? a. Compare practices within the facility against other high-performing facilities b. Use root cause analysis to identify gaps in meeting standards. c. Determine how current practice will affect future performance within the facility d. Establish work initiatives to promote a positive environment - A root cause analysis can be done to critically assess all factors that influence the issues. It focuses on variable that surround the consequence of an action or occurrence. A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign ​priority​? e. A client who has compound fractures of the tibia and humerus f. A client who reports severe vomiting and diarrhea g. A client who has soot markings around each naris following a house fire - compromise breathing ​-​ GREY’S ANATOMY! h. A client who reports night sweats and fever for the last week29. A nurse is providing ​discharge teaching​ to a client following a total knee arthroplasty. Which of the following information should the nurse include? (Select all that apply.) a. Contact information for the physical therapist b. Insurance information c. Medication guideline information d. Advance directives information e. Information about follow-up care Rationale: 30. A nurse manager overhears a provider and a staff talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first? a. Fill out an incident report regarding the situation b. Provide a staff inservice about client confidentiality c. Report the incident to the nursing supervisor d. Remind them that client information is confidential Rationale: key word is what should the nurse manager do first 31. A nurse receives change-of-shift report for the following four clients. Which of the following clients should the nurse assess ​first​? a. An older adult client who has bacterial pneumonia and a new onset of restlessness b. A middle adult client who has diabetes mellitus and a morning blood glucose of 172 mg/dL c. A client who has myasthenia gravis with ptosis and has developed urinary incontinence d. A client who is 1 day postoperative following hip fracture repair and reports a pain level of 6 on a scale from 0 to 10 Rationale:​ ABCs; key word is new onset32. A nurse enters a client’s room and observes a fire in the trash can. Identify the sequence of actions the nurse should take. (Move all the actions into the box on the right, placing them in selected order of performance.) - Remove the client from the area. - Activate the fire alarm system. - Confine the fire by closing doors and windows. - Extinguish the fire if possible. RACE!!!! 33. A nurse is caring for four clients. Which of the following tasks can be ​delegated to an assistive personnel​? a. Reviewing dietary instructions for a client who has kidney stones b. Monitoring a client who has a fluid restriction c. Obtaining a stool sample from a client who has renal failure d. Assessing a client who just returned from hemodialysis 34. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a ​sterile procedure​. Which of the following actions indicated the nurse is maintaining sterile techniques (Select all that apply.) a. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field b. Rests the cap of a solution container upside down on the sterile field c. H ​olds a bottle of sterile solution 15 cm (6 in) above the sterile field d. Opens the sterile pack by first unfolding the flap farthest from her body e. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field.​ ​- ​1 inch border not sterile Rationale:​ Fundamentals 7.0 page 46-47 http://atitesting.com/ati_next_gen/skillsmodules/content/surgical-asepsis/equipment/field.html 35. A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take? a. Convey the client’s request to the nurse who witnessed the consent. b. Explain the risks of the procedure to the client. c. Check to see if the medical record indicated the provider explained the procedure to the client. d. Notify the provider about the client’s concerns. 36. A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit. Which of the following responses by the nurse is appropriate? a. Please ask your relative about this, because I cannot share information about her. b. I will have your relatives nurse come and talk with you about her care. c. I’m not taking care of your relative today, so I don’t have the latest information d. Let me check your relatives medical record to see how she’s doing 37. A charge nurse observes a client fall during ambulation and notes that his gait belt was not place. In reviewing the incident report, the nurse finds no mention of gait belt. Which of the following ethical principles should guide the nurses subsequent actions? a. Fidelityb. Beneficence c. Nonmaleficence d. Veracity Rationale: state the truth of the gait belt in the incident report. 38. A charge nurse is making assignments for a med surg unit. Which of the following clients is appropriate to assign to a licensed practical nurse? a. A client who is scheduled to start oral nutrition 2 days after cerebrovascular accident b. A client who has dehydration and is being admitted from the ER c. A client who as emphysema and has oxygen saturation level of 92% d. A client who is scheduled to receive 2 units of RBCs following hip replacement Rationale:​ ​Leadership 6.0 (2013 version) pg 12: - Nurses can only delegate tasks appropriate for the skill and education level of the health care provider who is receiving the assignment - RNs ​cannot delegate​ the nursing process, client education, or tasks that require clinical judgement to LPNs or AP. 39. A charge nurse in the ER is supervising a nurse who is floating from the ​med-surg unit​. Which of the following assignments is appropriate for the float nurse? a. Complete a SAD PERSONS assessment scale for the client who has attempted suicide-why not this one? b. P ​erform a urinary catheterization for a client who has experienced a cerebrovascular accident c. Administer IV nitroglycerin to a client who is experiencing chest pain d. Set up a trauma room for an incoming client who was in a motor vehicle crash. Rationale: It is part of their scope practice for a med surg nurse to insert a urinary catheterization for patient who has CVA. this is the most stable patient a floated nurse could have. 40. A nurse is admitting a client who is scheduled for cholecystectomy. The client does not speak English and is accompanied by her adult daughter. Which of the following actions should the nurse take? a. Access a language line to interpret what is being said b. Ask the client’s daughter to interpret the conversation c. Talk loudly while facing the client d. Request the assistance of an assistive personnel who speaks the client’s language 41. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a LPN? a. Instructing a client who is obese about a low-fat diet b. Providing the first oral feeding to a client following a stroke c. Changing the dressing on a postoperative wound d. Referring a client to social services for assistance with transportation. Rationale: ATI 2016 pg. 42. A nurse is caring for a client who has an MI. ​The client’s daughter ask the nurse to review her father’s medical with her​. Which of the following responses should the nurse make? a. “I can tell you what the provider has written in the progress notes.” b. “We’ll ask your father’s provider to show you the laboratory results.” c. “You’ll have to make that request in writing in the medical records department.”d. “Your father will have to give permission for you to review the record.” Rationale: 43. A nurse in a clinic is reviewing lab reports for a group of clients. Which of the following diseases should the nurse​ report to the state health departments? a. Rotavirus b. Group B streptococcal disease c. Respiratory syncytial virus (according to cdc, NOT a nationally notifiable infectious disease) d. Pertussis Rationale: ​https://medlineplus.gov/ency/article/001929.htm 44. A nurse is the ER 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 take? a. Ask the adult neighbor to sign the consent form. b. Attempt to notify the client’s guardian to obtain consent. c. Witness the client signing the consent form. d. Obtain consent from the hospital administrator. Rationale: think about it ← stfu 45. A nurse is teaching a client who requires ​protective isolation​ due to ​immune system compromise​. Which of the following instructions should the nurse include to protect the client? a. “Make sure your visitors wear a gown when they are in your room.” b. “Remember to tell your family and friends not to bring you flowers.” c. “Wear gloves and a gown whenever you need to leave your room.” d. “Be sure to eat plenty of fresh fruit and vegetables.” Rationale: No live plants or flowers are allowed in the patient's room. Fruit and vegetables should be packaged or peeled and dairy products should be individually packaged and pasteurised. 46. A nurse in the emergency department is preparing a married 17-year-old client for an appendectomy. The client’s parents are en route to the facility but have not spoken with the surgeon. Which of the following actions should the nurse take? a. Have the client sign the consent form after the surgeon explains the procedure. b. Proceed with the preparation because the client signed a general consent form. c. Obtain consent from the client’s parents by telephone with another nurse listening as a witness. d. Delay the surgery until the parents arrive to sign the consent form. Rationale: ATI 16 pg. 36 ​ Emancipated minors (minors who are independent from their parents, such as a married minor) can provide informed consent for themselves. 47. A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate? a. “I understand, and it’s not too late to change your mind.” b. “You’ll be fine. You’ll receive a prescription for pain medication.” c. “Why didn’t you discuss your concerns with your provider.” d. “If you have the procedure now, you won’t have to deal with pain and disability later.” Rationale: Patient advocate. And respecting autonomy. The rest are non therapeutic response.48. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? a. False imprisonment b. Libel c. Assault d. Battery Rationale: ATI 16 pg. 42 Intentional Torts: ​Battery: ​Intentional and wrongful physical contact with a person that involves an injury or offensive contact (restraining a client and administering an injection against his wishes). 49. A nurse is completing discharge teaching with a client who is being treated with tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? a. “I need to take my prescribed medication for 3 months.” ​6-12 months b. “I need to have a TB skin test done once per year.” c. “I should wear a mask while around my family.” d. “I should have a sputum culture done every 2 to 4 weeks.” Rationale: ​Examination of the sputum of patients with pulmonary tuberculosis at 2- to 4-week intervals until conversion occurs is important for several reasons. 50. A nurse in the emergency department is assessing a client who is ​unconscious​ following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? a. Delay the surgery until the nurse can obtain informed consent b. Obtain telephone consent from the facility administrator before the surgery c. Transport the client to the operating room without verifying informed consent. d. Ask the anesthesiologist to sign the consent. Rationale: Research. ​The health care providers may rely upon implied consent only in the absence of consent. It may not be necessary to obtain consent if a person requires emergency tx to save their life (unconscious) -reasons why treatment was necessary should be fully explained once they've recovered. Or an immediate requires of an additional emergency procedure. 51. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client’s need for which of the following to manage the tracheostomy at home? (Select all that apply.) a. Petroleum jelly - ​flammable around oxygen b. Betadine solution c. Obturator d. Oxygen tank e. Suction machine Rationale: Research: Home Tracheostomy Care→ REVIEW petroleum jelly around the stoma; Obturator when replacing the current one in your neck when cleaning; 02 patient might be sob; suction machine for excessive mucus and maintain a patent airway while doing tracheostomy cleaning ​http://www.tracheostomy.com/resources/pdf/university_kentucky.pdf -ATI Practice Leadership 2016 B: The client should avoid the use of petroleum jelly b/c oils and greases are flammable and can ignite, causing serious injury to the client. The nurse should instruct the client to use a water-based lubricant when using oxygen.52. A nurse is completing discharge teaching about dietary supplements for ​nitrogen loss ​with a client who has cancer. Which of the following nutrients should the nurse recommend the client increase? a. Fiber b. Fatty acids c. Protein d. Carbohydrates Rationale: Research: ​An evaluation of protein quality must therefore take into account the different processes involved in amino acid and nitrogen homeostasis. REVIEW http://jn.nutrition.org/content/130/7/1868S.full 53. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? a. Administer a nasogastric tube feeding b. Pick up the meal trays after lunch c. Determine adequacy of ventilator settings d. Plan break times for assistive personnel Rationale: ATI 16 Pg. 9 Table 1.4 Administering enteral feedings. 54. A case manager is preparing a client who has a spinal cord injury for discharge from the rehabilitation setting to home. Which of the following actions is the​ case manager’s priority ​when creating the ​discharge plan​? a. Identify desired outcomes for the client’s home care b. Facilitate client referrals for community resources c. Advocate strategies for cost-effective home care d. Arrange for a home environment assessment Rationale: ATI 16 Pg. 25 Facilitating referrals and the use of community resources. 1 Priority Uno (2016) 1. ​ A client is brought to the emergency department following a ​motor-vehicle crash​. ​Drug use​ is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly ​refuses to provide the specimen​. Which of the following is the appropriate action by the nurse? a. Tell the client that a catheter will be inserted. b. ​ Document the client’s refusal in the chart​. c. Assess the client for urinary retention. d. Obtain a provider’s prescription for a blood alcohol level. The Patient Self-Determination Act (PSDA) stipulates that on admission to a health care facility, all clients must be informed of their right to accept or refuse care. Competent adults have the right to refuse treatment. If the client refuses a treatment or procedure, the client is asked to sign a document indication that he understands the risk involved with refusing the TX or procedure, and that he has chosen to refuse it. 2. ​ A nurse I making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a ​licensed practical nurse? a. Pick up the meal trays after lunch.- CNA b. ​Administer a nasogastric tube feeding.​- LVN can do basic nursing skills c. Plan break times for assistive personnel.- RN does management d. Determine adequacy of ventilator settings.- ASSESSMENTS are done by RNs3. A ​nurse preceptor​ is evaluating a​ newly licensed nurse’s​ competency in assisting with a sterile procedure. Which of the following actions indicates the newly licensed nurse is ​maintaining sterile technique​? (SATA) a. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field ​- 1 in. b. ​ Opens the sterile pack by first unfolding the top flap away from her body c. Prepares a container of sterile solution on the field after putting on sterile gloves -​ before d. ​Removes the outside packaging of a sterile instrument before dropping it onto the sterile field e. Holds the sterile solution bottle with the label facing up​ - hold with the ​label in the palm​ of the hand so that the solution does not run down the label..​i’m trying to visualize this, so isn’t this right cuz if you’re pouring, the label would be facing up, on your palm?? 4. ​ A nurse enters a client’s room and identifies that the client is ​receiving too much IV fluid​ because the IV pump is ​not working​ properly. Which of the following actions should the nurse take ​first​? a. ​ Auscultate the client’s lungs.​ - assessment first b. Notify the provider. c. Place a faulty equipment tag on the pump. d. Complete an incident report. 5. ​ A nurse is planning care for a group of clients and can ​delegate​ care to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse ​assign to the LPN​? a. ​ Reinforcing​ teaching with a client who is learning to self-administer insulin b. Ambulating a client who is scheduled for discharge later in the day ​- AP c. Administering morphine IV bolus to a client who is hr postoperative ​- RN d. Admitting a new client who has chronic back pain to the unit ​- RN 6.​ A nurse is supervising a ​newly licensed nurse​ who is performing surgical asepsis. ​After donning a sterile gown and gloves​, which of the following actions by the newly licensed nurse demonstrates ​correct aseptic technique? a. The nurse applies goggles. b. The nurse turns her back to the sterile field. c. ​The nurse holds her hands above her waist. d. The nurse puts on a face mask. 7. ​ A nurse who is caring for a group of clients delegates collection of vital signs to an ​assistive personnel (AP).​ Which of the following actions should the nurse take to ​evaluate the delegated task​? a. ​Review vital sign trends at the end of the shift. b. Recheck vital signs that are outside the expected reference range. c. Ask the AP to write a summary of the delegated tasks during the shift. d. Compare the vital signs the AP obtained with those taken by another AP on a previous shift. 8.​ A nurse is caring for four clients. Which of the following tasks can be ​delegated to an assistive personnel​? a. ​ Obtaining a stool sample from a client who has renal failure b. Monitoring a client who has a fluid restriction c. Assessing a client who just returned from hemodialysis -​ RN (assessment) d. Reviewing dietary instructions for a client who has kidney stones ​- RN (teaching)9. ​ A nurse is ​triaging​ a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment ​first​? a. ​A client who has a neck injury and is unable to breathe spontaneously​ -​ airway b. A client who has two open chest wounds with a left tracheal deviation c. A client who has major burns over 75% of her body surface area d. A client who has bipolar disorder and is exhibiting signs of hallucination 10.​ A nurse manager is reviewing ​guidelines for informed consent​ with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was ​effective​? a. “A family member can interpret to obtain informed consent from a client who is deaf.” b. ​ “Consent can be given by a durable power of attorney.” c. “Guardian consent is required for an emancipated minor.” ​emancipated minors can give their own consent d. “The nurse can answer any questions the client has about the procedure.” ​- provider is responsible for this 11.​ A nurse is caring for four clients. For which of the following clients should the nurse ​collaborate with the facility ethics committee​? a. A middle adult client who leaves the facility against medical advice ​- right to refuse treatment b. An older adult client who has advanced directives on file ​- has advance directives c. A young adult client who is participating in a medical research study ​- of age d. ​ An adolescent client whose parents refuse a blood transfusion for religious reasons 12.​ A nurse in an ambulatory care setting is orient a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an ​objective of telehealth​? a. Assessing client needs b. Developing client treatment protocols c. Providing medication reconciliation d. Establishing communication between providers 13​. A nurse is providing discharge teaching to a client who has a ​new diagnosis of diabetes​. The client expresses concern about the ​cost of blood-glucose monitoring supplies​. Which of the following actions should the nurse take? a. ​ Refer the client to the social services department. b. Provide the client with a week’s worth of supplies from the hospital - (still needs help paying after) c. Ask the provider about the possibility of less frequent monitoring - (pt needs to monitor often) d. Recommend the client reuse the testing lancets - (breaks the safety & infection protocol) Rationale Community ATI PDF p53​: referral to social services to eliminate financial difficulties or other sources of stress. 14. ​ A charge nurse is receiving ​change-of-shift report.​ Which of the following situations should the charge nurse address​ first? a. A nurse on the previous shift wrote an incident report about a medication error. b. Two staff members have called to say they will be absent. ​- ​soo I’m thinking this cuz they’re down on nurses c. Transport assistance is unavailable to take a client to occupational therapy. d. ​ The emergency department nurse is waiting to give report on a new admission.Rationale Leadership ATI PDF p5​: Priority setting requires that decisions be made regarding the order in which: 1. Clients are seen 2. Assessments are completed 3. Interventions are provided 4. Steps in a client procedure are completed 5. Components of client care are completed. 15. ​ A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to ​demonstrate appropriate time management​? a. Complete required tasks. b. Review the client’s new laboratory values. c. ​Determine client care goals​ ​(set/ plan goals) d. Document assessment data. Rationale Leadership ATI PDF p7:​ Time management is a cyclic process. Time initially spent developing a plan will save time later and help to avoid management by crisis. Set goals and plan care based on established priorities and thoughtful utilization of resources. Complete one client care task before beginning the next, starting with the highest priority task. Reprioritize remaining tasks based on continual reassessment of client care needs. At the end of the day, perform a time analysis and determine if time was used wisely. 16. ​ A charge nurse is reviewing information about ​HIPAA ​with a group of staff nurses. Which of the following statements by a staff nurse indicates​ understanding? a. “Clients who participate in research studies forfeit their HIPAA right to privacy.” b. “HIPAA allows facility-specific coding of client health care information to ensure privacy.” c. “HIPAA prohibits the uploading of photographs of ​client’s providers​ to social media sites.” d. ​“HIPAA allows clients to request a review of their own medical records.” Rationale Leadership ATI PDF p40:​ The rights of clients to obtain a copy of their medical record and to submit requests to amend erroneous or incomplete information. A requirement for healthcare and insurance providers to provide written information about how medical information is used and how it is shared with other entities (permission must be obtained before information is shared). The rights of clients to privacy and confidentiality 17​. A nurse is caring for a client who has a tumor. The provider recommends surgery. The ​client refuses, but the client’s partner wants the surgery performed​. Which of the following is the ​deciding factor ​in determining if the surgery will be done? a. ​ Whether the client understands the risk of refusing the procedure b. Whether the facility ethics committee reached a consensus on the case c. Whether the partner is the client’s durable power of attorney for health care d. Whether the client’s refusal is based on religious belief Rationale Leadership ATI PDF p35​: If the client refuses a treatment or procedure, the client is asked to sign a document indicating that he understands the risk involved with refusing the treatment or procedure, and that he has chosen to refuse it. 18. ​ A charge nurse is planning the care of four newborns. An assistive personnel and licensed practical nurse are available for staffing. Which of the following tasks should the nurse ​assign to a licensed practical nurse? a. Conduct the newborn hearing screening.- (RN assessment) b. ​Administer a hepatitis B vaccine. c. Perform a New Ballard screening.- (RN assessment) d. Obtain vital signs. - (CNA)Rationale Leadership ATI PDF p9:​ Administering medication (excluding IV medication in some states) 19​. During a staff meeting a unit manager reviews the results for documenting client education and finds that they are ​below the benchmark​. Which of the following strategies should the nurse manager implement first? a. Train LPNs to reinforce teaching with clients using a standardized teaching plan. b. Determine factors that interfere with the documentation of client education. c. Include documentation of client education as part of unit nurses’ annual performance evaluation. d. Offer incentives for the staff once the unit’s results are back in adherence with the benchmark. Rationale Leadership ATI PDF p12​: Steps in quality improvement process: 1) Standards are made available to employees by way of policies and procedures. 2) Quality issues are identified by staff, management, or risk management department. 3) An interprofessional team is developed to review the issue. 4) The current state of structure and process related to the issue is analyzed. 5) Data collection methods are determined 6) Data is collected, analyzed, and compared with the established benchmark. 7) If the benchmark is not met, possible influencing factors are determined. A root cause analysis can be done to critically assess all factors that influence the issue. 8) Potential solutions or corrective actions are analyzed and one is selected for implementation. 9) Educational or corrective action is implemented. 10) The issue is reevaluated at a preestablished time to determine the efficacy of the solution or corrective action. 20.​ A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that preventing client injury by removing a fall hazard ​demonstrates which of the following ​ethical principles? a. Utility b. Autonomy c. ​Nonmaleficence d. Veracity Rationale Leadership ATI PDF p47​: Nonmaleficence: The nurse’s obligation to avoid causing harm to the client 21.​ A nurse is caring for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past 24 hr (improvement) b. A client who has diabetes mellitus and reports paresthesia in his fingers and toes (ABC--circulation) c. A client who has a nasogastric tube and has crackles in the lungs ​(ABC--airway)​ - means that tube is in the lungs and not in stomach. Compromises airway d. A client who has a new diagnosis of Graves’ disease and a TSH level of 0.2 microunits/mL Rationale Leadership ATI PDF p5:​ ABC--airway; Breathing is necessary for oxygenation of the blood to occur. 22.​ A charge nurse is planning to ​evacuate clients​ on the unit because there is a ​fire ​on another floor. Which of the following clients should the nurse ​evacuate first a. A client who is in Buck’s traction for a left hip fracture (can’t necessarily move too much)b. A client who is 1 day postoperative following thoracic surgery and has a chest tube (possible physical instability) c. A client who is confused and restrained for safety (still needs continual nursing care/assessment) d. ​A client who is receiving IV chemotherapy and is ambulatory Rationale Leadership ATI PDF p73:​ First, discharge or relocate ambulatory clients​ requiring minimal care. ​Next, make arrangement for continuation of care for clients who require some assistance, which could be provided in the home or tertiary care facility. Do not discharge or relocate clients who are unstable or require continuing nursing care and assessment unless they are in imminent danger. 23​. A nurse enters the room of a client who is unconscious and finds that the ​client’s son is reading her electronic medical records​ from a monitor located at the bedside. Which of the following actions should the nurse take ​first​? a. Recommend the son meet with the provider to get information about his mother’s condition. b. Report the possible violation of client confidentiality to the nurse manager. c. Complete an incident report regarding the breach of the client’s confidentiality. d. ​Log out the computer so that the client’s son is unable to view his mother’s information​. Rationale Leadership ATI PDF p40 &42: Log off from the computer before leaving the workstation to ensure that others cannot view protected health information (PHI) on the monitor Nurses who disclose client information to an unauthorized person can be liable for invasion of privacy, defamation, or slander. Intrusion into a client’s private affairs or a breach of confidentiality 24. ​ A nurse is preparing a client for cardiac catheterization. ​Just before the procedure, ​the client ​asks the nurse about the risks of the procedure.​ Which of the following actions should the nurse take? a. Explain the risks of the procedure to the client. ​- HCP needs to do this b. Convey the client’s request to the nurse who witnessed the consent. c. Check to see if the medical record indicates the provider explained the procedure to the client. d. ​Notify the provider about the client’s concerns. Rationale Leadership PDF p47​: Notify the provider if the client has more questions or does not understand any of the information provided. (The provider is then responsible for giving clarification.) 25. ​ A nurse is prioritizing care after receiving change-of-shift report on four clients. Which of the following clients should the nurse assess​ first​? a. A client who reports a headache with sensitivity to light b. A client who reports an urge to void but has not urinated during the prior shift c. A client who reports indigestion and pain in her jaw d. A client who reports feeling lightheaded when he stands up from a lying position Rationale: Med surg page 184. SUBJECTIVE DATA: ​Chest pain​ might occur with or without exertion. ​Pain might radiate to jaw,​ left arm, through the back, or to the shoulder. E ects might increase in cold weather or with exercise. Other findings can include dyspnea, ​nausea​, fatigue, and diaphoresis. 26​. A charge nurse notices that two staff nurses are ​not taking meal breaks​ during their shifts. Which of the following actions should the nurse take​ first? a. Discuss time management strategies with the nurses. b. Determine the reasons the nurses are not taking scheduled breaks. c. Provide coverage for the nurses’ breaks. d. Review facility policies for taking scheduled breaks.27.​ A nurse is preparing to d​elegate bathing and turning ​of a newly admitted client who has end-stage bone cancer to an experienced ​assistive personnel (AP).​ Which of the following assessments should the nurse make ​before delegating care? a. Has the AP checked the client’s pain level prior to turning her? b. Is the client’s family present so the AP can show them how to turn the client? c. Has data been collected about specific client needs related to turning? d. Does the AP have the time to change the client’s central IV line dressing after turning her? 28​. A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion ​of the report? a. A ​prescribed​ consultation b. The client’s vital signs ​- assessment c. The client’s name - ​- situation d. ​The client’s code status 29.​ A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an ​occupation therapist is necessary? a. “I need some help planning my meals to maintain my weight.” b. “I am tired of having pain in my joints all the time.” c. “I’m having difficulty climbing the stairs at my house.” d. “I will need assistance with bathing.” 30. ​ A nurse in the emergency department is caring for a ​16-year-old client​ who reports abdominal pain and is ​accompanied by an adult neighbor​. The provider diagnoses a ruptured appendix and states that the client requires an ​emergency appendectomy​. Which of the following actions should the nurse? a. Ask the adult neighbor to sign the consent form. b. Obtain consent from the hospital administrator. c. Witness the client signing the consent form. d. Attempt to notify the client’s guardian to obtain consent. 31.​ A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the ​highest priority? a. A client who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds b. A client who has COPD and has an oxygen saturation of 90% c. A client who had a cholecystectomy 6 hr ago and is requesting pain medication d. A client whose TPN was discontinued 4 hr ago and is requesting clear liquids 32. A charge nurse suspects that a staff nurse is​ chemically impaired.​ Which of the following actions should the charge nurse take? a. Assign clients who are not prescribed narcotics to the staff nurse. b. ​Collect data about the staff nurse to support further action. ​? c. Report the staff nurse to the facility ethics committee. ​? d. Counsel the staff nurse about substance use.33. ​ A nurse is assessing a client’s comprehension of a ​pulmonary function test ​prior to the procedure. Which of the following client statements indicates to the nurse an ​understanding ​of the procedure? a. “I will be given contrast dye during this test.” b. “I might have to wear a nose clip during this test.” c. “I might have a tube inserted into my airway during the test.’ d. “I will run on a treadmill during this test.” 34. ​ A nurse in the emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined ​first? a. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood b. An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10 c. An older adult client who has dyspnea and a respiratory rate of 26/min d. An adult client who has large ecchymoses on both legs 35.​ A home health nurse finds piles of newspapers in the hallway of a client’s home. The nurse explains the need to discard the newspapers for safety reasons. The client agrees to move the newspapers into the living room. Which of the following conflict resolution strategies has the nurse used? a. Collaborating - ​Both parties set aside their original individual goals work together to achieve a new common goal. b. Smoothing - ​One party attempts to “smooth” another party by trying to satisfy the other party. c. Accommodating - ​One party sacri ces something, allowing the other party to get what it wants. This is the opposite of competing. The original problem might not actually be resolved. d. ​ Compromising ​- ​Each party gives up something. To consider this a win/lose-win/lose solution, both parties must give up something equally important. If one party gives up more than the other, it can become a win-lose solution. 36.​ A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to an ​assistive personnel? a. Advising a client on self-administration of acetaminophen b. Informing a family of a client’s progress in physical therapy c. Teaching a client to perform a finger-stick for testing blood glucose levels ​RN d. Performing post mortem care prior to transferring the client to the morgue 37.​ A nurse is providing discharge teaching to a client following a total knee arthroplasty. Which of the following information should the nurse include (SATA) a. Advance directives information b. Contact information for the physical therapist c. Medication guidelines information d. Insurance information e. Information about follow-up care Rationale: ATI MS 436 ​The client requires extensive physical therapy to regain mobility. The client can be discharged home or to an acute rehabilitation facility. If discharged home, outpatient or in‑home therapy must be provided. Home care should be available for 4 to 6 weeks. ● Provide medications as prescribed. Focus needs to be about pain medications. This promotes client participation in early ambulation. ◯​Analgesics​: ​Opioids (epidural, PCA, IV, oral), NSAIDs ◯ ​Peripheral nerve blockade:​ ​Inject the femoral or sciatic nerve with a local anesthetic, or the client can receive a continuous infusion of local anesthetic directly into sciatic or femoral nerve.■ A continuous peripheral nerve block provides localized pain relief. ■ Monitor for systemic effects of local anesthetic, such as metallic taste in the mouth, tinnitus, slurred speech, decreased respiratory rate, hypotension, bradycardia, restlessness, or seizure. ◯ ​Antibiotics:​ ​Prophylaxis is generally administered 30 min before the surgical incision is made and postoperatively to prevent infection. ◯ ​Anticoagulant:​ ​Warfarin, fondaparinux, rivaroxaban, or low‑molecular‑weight heparin, such as enoxaparin. The client can have a prescription for sequential compression devices, foot pumps, and/or anti embolism stockings to prevent venous thromboembolism formation that can develop into DVT. Always need to provide patient information about follow up care on any post-op procedure. 38​. A nurse is planning to discharge a client who has terminal cancer and suggests that the family might benefit from ​respite services.​ When the client’s partner asks how this service can help, which of the following responses by the nurse is appropriate? a. “This service offers psychological interventions during and after your wife’s illness.” b. “The clinicians help reduce the severity of your wife’s physical problems.” c. “This service delivers meals and supplies to reduce your errands away from home.” d. “It makes it possible for you to have some time away from caring for your wife.” Rationale: ​● Assist in removing or reducing factors that contribute to stress by referring caretakers of older adult clients to respite services. 39. ​ A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include? a. Warm the hands prior to piercing the skin. b. Cap the lancet prior to putting it in the trash. ​- no capping c. Elevate the arm for 1 min before taking the blood sample. ​- dependent position d. Obtain the blood sample from the finger pads. Rationale: Massage or Warm fingers prior to piercing to promote blood flow in preparation for the finger stick. 40. ​ A nurse is assessing a client who had a recent stroke. Which of the following findings should indicate the need for referral to an ​occupational therapist​? a. Receptive aphasia→ unable to understand language in its written or spoken form b. Facial drooping→ speech therapist c. Memory loss d. 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. Occupational Therapist- to learn how to perform ADLs. 41​. A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the ​highest priority ​to have available in response to a ​bioterrorism event​? a. A network for communication between staff members and families b. A mental health specialist on the response team c. A sufficient supply of personal protective equipment d. A system for tracking client information ATI Community 66. ​Locate all equipment and supplies needed for disaster management, including hazmat suits, infectious control items, medical supplies, food, and potable (drinkable) water. Detail a plan to replenish these regularly.42.​ A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the ​state health department​? a. Rotavirus b. Pertussis c. Respiratory syncytial virus d. Group B streptococcal disease ATI Community 64. National Notifiable Disease: Or Whooping cough 43.​ A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment used for a client who has ​Clostridium difficile​. Which of the following solutions should the nurse recommend to ​clean the equipment? a. Chlorine bleach b. Triclosan c. Chlorhexidine d. Isopropyl alcohol Rationale: http://www.cdiff-support.co.uk/tips/ Clostridium Difficile Spores are highly resistant to cleaning agents and will live for between 70-90 days outside the body and are only killed by cleaning agents containing Chlorine Bleach. 44​. A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse ​suspects elder abuse.​ Which of the following actions should the nurse take? a. Treat and discharge the client. b. Ask the client’s son to go to the waiting area. c. File an incident report. d. Ask the client about his injuries with the son present. Safety Measures: Priority. 45. ​ A nurse is completing discharge teaching with a client who is being treated for tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? a. “I need to take my prescribed medication for 3 months.” b. “I should have a sputum culture done every 2 to 4 weeks.” c. “I need to have a TB skin test done once per year.” d. “I should wear a mask while around my family.” Rationale ATI MS. 138 ​Inform the client that sputum samples are needed every 2 to 4 weeks to monitor therapy effectiveness. Clients are no longer considered infectious after three consecutive negative sputum cultures, and may return to former employment. 46. ​ An older adult client is awaiting surgery for a ​fractured right hip.​ The nurse should recognize that which of the following can be ​delegated to an assistive personnel​? a. Checking the pulses of the client’s right foot b. Recording the client’s vital signs c. Turning the client d. Determining the client’s pain level Examples of Tasks that can be Delegated by the RN To LPNs To AP· Reinforcement of client teaching · Monitoring client clinical manifestations after the initial RN assessment and evaluation · Tracheostomy Care · Suctioning · Reviewing patency and placement of a nasogastric tube · Enteral feeding administration · Urinary Catheter insertion · Medication administration (excluding intravenous medications – state specific) · Activities of daily living (ADLs) · Bathing, Grooming, Dressing, Toileting, Ambulating, Feeding (without swallowing concerns), Positioning, Bed making · Specimen Collection · Intake and output · Vital signs (stable clients) 47​. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). Which of the following is an ​appropriate task for the AP? a. Inspect the skin of a newborn who is receiving phototherapy. – Assess b. Answer the parents’ questions about newborn circumcision. - Teaching c. Show a new mother how to change the newborn’s diaper. - Teaching d. Obtain the weight of a newborn that is receiving formula Rationale: Review table on #46. 48​. A nurse is orienting a newly licensed nurse about the use of ​restraints​. Which of the following statements by the newly licensed nurse indicates an ​understanding​ of the teaching? a. “A provider can write a prescription for restraints ‘as needed’.” b. “I need to tie the restraint to the part of the bed frame that moves.” c. “I should tie the restraints using a square knot.”​ - ​quick release d. “I will remove a client’s restraints every 4 hours.” ATI Funda 59 ​● Use a quick‑release knot to tie the restraints to the bed frame (loose knots that are easy to remove) where they will not tighten when raising or lowering the bed. ​Assess skin integrity, and provide skin care according to the facility’s protocol, usually every 2 hr. ATI Leadership 57 PRN Rx for restraints are NOT permitted. 49.​ An infection control nurse is planning an education program for a group of newly licensed nurses. Which of the following infections should the nurse include when discussing illnesses requiring ​droplet precautions? a. Mumps ​- ​droplet b. Rubeola ​- measles - airborne c. Varicella ​- airborne d. Rotavirus ​- contact 50.​ A nurse is caring for a client who has cancer. The client and her partner are asking the nurse about hospice care.​ Which of the following statements by the nurse is ​appropriate? a. “Hospice care will prolong the life expectancy of clients who are terminally ill.” b. “Hospice care is a multidisciplinary program for clients who are terminally ill.”c. “Hospice care is helpful for clients at various stages of chronic illness.” d. “Hospital access is no longer available for clients who are in hospice care.” 51. ​ A nurse is planning care for a client who has ​Addison’s disease.​ Which of the following tasks should the nurse plan to delegate to an ​assistive personnel? a. Decide how often to measure vital signs. b. Explain to the client about a 24-hr urine specimen collection. c. Determine the client’s muscle strength prior to ambulation. d. Remind the client to change positions slowly. 52.​ A charge nurse discovers that a staff nurse on the unit has made ​repeated medication errors.​ Which of the following actions should the charge nurse take ​first? a. Notify the risk management department of the situation. b. Review with the nurse the principles of medication administration. c. Ask the nurse to describe her medication administration procedure. d. Identify education opportunities for the nurse regarding safe medication administration. 53. ​ A case manager is reviewing documentation on several clients and notes ​a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. ​The nurse manager should identify that which of the following torts has occurred? P. 42 ch 3 a. Libel-​ talking bad about someone via writing it in notes b. Battery c. Slander d. Negligence 54.​ A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an ​appropriate procedure for taking care of this client’s ring? a. Place the client’s ring in the facility safe. b. Tape the ring securely to the client’s finger. c. Place the ring in the bad with the client’s clothing. d. Agree to keep the ring for the client until after surgery. 55. ​ A nurse is prioritizing postpartum care for four clients. Which of the following actions should the nurse take ​first? a. Assist a client who requests help breastfeeding her 4-hr-old newborn. b. Administer RH immune globulin to a client who is Rh-negative and 6 hr postpartum. c. Check uterine tone for a client who received methylergonovine. d. Instruct a client who has an episiotomy about a sitz bath. 56.​ 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? a. Withhold the benzodiazepine but continue the opioid. ​- not sure b. Contact the provider about replacing the opioid with an NSAID. c. Administer the benzodiazepine but withhold the opioid. d. Continue the medication dosages that relieve the client’s pain.57.​ A nurse is observing an assistive personnel (AP) administer 0.9% sodium chloride ​enema ​to an adult client. For which of the following actions by the AP should the nurse​ intervene? REPEAT a. Administers the solution at room temperature b. Points tubing in the direction of the umbilicus during insertion c. Position the client on her left side with knees flexed d. Inserts the tubing 8 cm (3.1 in) into the rectum 58.​ A nurse is providing information to a client about ​advance directives.​ The nurse should explain that advance directives include which of the following? a. Instructions regarding treatments the client desires or does not desire b. Information regarding the disposition of the client’s body upon death c. Information regarding organ donation d. A form with directions for contacting next of kin 59.​ A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? a. A client who has peripheral vascular disease ad has an absent pedal pulse in the right footABCS-absent pulse means NO CIRCULATION = necrosis it can make b. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy. c. A client who has methicillin-resistant ​Staphylococcus aureus​ (MRSA) and has an axillary temperature of 38C (101F) d. A client who is postoperative following a laminectomy 12 hr ago and is unable to void 60. ​ A staff development nurse is giving an in-service presentation about advocacy in nursing. Which of the following statements by a nurse indicates an understanding of the role of a client ​advocate​? ​P . 36 ch 3 a. “In the role of client advocate, I should take responsibility for coordinating each client’s care.” b. ​“As a client advocate, I will suggest the best course of action for clients who are indecisive.”- advocates assit them without control the situation. c. “My role as a client advocate is to empower the clients to make informed healthcare decisions.” d. “As a client advocate, I will adhere to the provider’s prescribed treatments.” 61.​ A nurse manager observes an assistive personnel ​(AP) incorrectly transferring a client ​to the bedside commode. Which of the following actions should the nurse take ​first? a. Refer the AP to the facility procedure manual. b. Instruct the AP to request assistance when unsure about a task. c. Help the AP assist the client with the transfer. d. Demonstrate the proper client transfer technique for the AP. 62.​ A nurse at the local health department is caring for four clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? https://medlineplus.gov/ency/article/001929.htm a. ​Chlamydia trachomatis b. Pediculosis capitis c. Impetigo contagiosa d. ​Candida albicans63.​ A charge nurse witnesses ​two nurses having a loud discussion ​at the nurses’ station about not wanting to care for a client who has drug-resistant tuberculosis. Which of the following actions should the charge nurse take? a. Escort the nurses to the nurses’ lounge to continue the discussion. b. Recommend that both nurses be terminated. c. Make arrangements to take over the client’s care. d. Contact the house supervisor to mediate the conflict. 64​. A newly licensed nurse is floating to an unfamiliar unit and ​determines that he does not have sufficient experiences to safely care for his assigned clients. ​Which of the following actions should the nurse take? a. Accept the assignment with help from assistive personnel on the unit.- NEVER EVER ACCEPT AN ASSIGMENT YOU CANNOT DO! - prof katia told me in nursing ethics. b. Request that the charge nurse modify the assignment.​- ​bring attention to the charge nurse and negotiatie ad new assignment , then take it up to chain of command , then file a assigment despite objection . c. Document the concern in the nurse’s notes. d. Notify the risk manager.- you must follow chain of command, the first one to talk to is the charge nurse . 65. ​ A nurse is conducting an in-service about the ​nursing code of ethics​ with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching as an example of advocacy? a. Recommending a referral for a client who requires physical therapy b. Suggesting a client’s partner attend a support group for emotional support c. Evaluating a client’s home for safety hazards d. Completing an incident report following a medication error 66​. A charge nurse in the emergency department is supervising a nurse who is floating from the medical-surgical unit. Which of the following assignments is ​appropriate for the float nurse? a. Administer IV nitroglycerin to a client who is experiencing chest pain. b​. Perform a urinary catheterization for a client who has experienced a cerebrovascular accident. c. Set up a trauma room for an incoming client who was in a motor-vehicle crash. d. Complete a SAD PERSONS assessment scale for a client who has attempted suicide. 67​. A home health nurse is assessing the home environment during an initial visit to a client who has history of falls. Which of the following findings should the nurse identify as ​increasing the client’s risk for falls? (SATA) a. A folding chair without arm rests b. A wheeled office chair at the client’s computer desk c. A throw rug covering some cracked vinyl flooring in the kitchen d. A two-wheeled walker used to assist the client with ambulation e. A raised vinyl seat on the toilet in the bathroom 68.​ A nurse in a long-term care facility should identify that which of the following will ​provide security​ for clients who have ​dementia​? a. Turning off room lights at night b. Using a facility-wide paging system c. Restricting space to reduce pacing d. Setting alarms on exits69​. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is​ disoriented and has a cardiac arrhythmia. ​Which of the following actions should the nurse take? a. Have the client sign a consent for treatment. b. Notify risk management before initiating treatment. c. Proceed with treatment without obtaining written consent. d. Contact the client’s next of kin to obtain consent for treatment. 70.​ A nurse is reviewing the medication administration record of a client and notices that an additional dose of medication has been administered. Which of the following actions should the nurse take ​first? a. Inform the nursing supervisor. b. Notify the provider c. Observe the client’s condition. d. Complete an incident report. [Show More]

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