ATI Leadership QUESTIONS AND ANSWERS 2019 C
Form C
1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change
... [Show More] in wound care procedure. Which of the following findings indicate wound healing?
a. Erythema on the skin surrounding a client’s wound
b. Inflammation noted on the tissue edges of a client’s wound
c. Increase in serosanguinous exudate from a client’s wound
d. Deep red color on the center of a client’s wound
2. A nurse received change-of-shift report at 0700 for four clients. Which of the following actions should the nurse perform first?
a. Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400
b. Obtain a breakfast tray for a client who received a morning dose of insulin aspart
c. Replace a client’s enteral nutrition feeding solution that has been hanging for 24 hr
d. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse?
a. A client who sustained a concussion and is being monitored for complications
b. A client who has a brain tumor and is admitted for chemotherapy
c. A client who has Gullain-Barre syndrome and a tracheostomy
d. A client who has multiple sclerosis and ataxia
4. A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?
a. My durable power of attorney for health care is part of my advance directives
b. My doctor will need to provide approval for the decisions outlined in my living will
c. Once I sign my living will, a family member must co-sign it
d. I will wait until I have a serious health problem to sign my advance directives
5. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first?
a. Establish measurement criteria for infant safety systems
b. Evaluate the selected infant safety system
c. Choose an infant safety system
d. Identify the industry standards for infant safety
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. Respiratory therapist
b. Physical therapist
c. Occupational therapist
d. Speech therapist
7. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client’s risk for falls? (Select all that apply.)
a. A wheeled office chair at the client’s computer desk
b. A two-wheeled walker used to assist the client with ambulation
c. A throw rug covering some cracked vinyl flooring in the kitchen
d. A folding chair without arm rests
e. A raised vinyl seat on the toilet in the bathroom
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 licensed practical nurse?
a. An adolescent client who is newly diagnosed with diabetes and requires teaching regarding insulin administration
b. A middle adult client who had a below-the-knee amputation and requires a dressing change
c. An older adult client who has lung cancer and has periodic episodes of severe dyspnea
d. A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus
9. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?
a. Reinforce the potential consequences of not having this information on record to the nursing staff
b. Ask nurses who are caring for clients without this information in the medical record to obtain it
c. Meet with nursing staff to review the policy regarding advance directives
d. Remind nurses to obtain this information during the admission process
10. A nurse is caring for a group of clients. Which of the following clients should the nurse see first?
a. A client who is postoperative and has a fever
b. A client whose pressure ulcer has serosanguinous drainage on the dressing
c. A client who has diabetes mellitus and is diaphoretic
d. A client who has a fractured hip and reports a pain level of 7 on a scale from 0 to 10
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 has pneumonia and requires a tracheostomy dressing change
b. A client who has a new colostomy and requires discharge teaching
c. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea
d. A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg - check
12. A nurse manager discovers there is a conflict between nurses working the day shift and nurses working the night shift. Which of the following actions should the nurse manager take first?
a. Encourage the nurses to resolve the conflict autonomously
b. Meet with a committee of nurses from each shift to discuss issues related to the conflict
c. Gather information regarding the situation
d. Acknowledge the conflict and encourage the nurses to focus on working as a team
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. Remove the client’s clothing
b. Don personal protective equipment - check
c. Report the incident to OSHA
d. Irrigate the exposed area with water
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. Measure the client’s vital signs
b. Call the provider
c. Inform the nurse manager
d. Complete an incident report
15. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
a. Increased temperature
b. Generalized rash over trunk
c. Report of photophobia
d. Decreased level of consciousness
16. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway?
a. The route of antibiotic therapy on the care pathway was changed from IV to PO
b. An allergy to penicillin required an alternative antibiotic to be prescribed
c. A blood culture was obtained after antibiotic therapy had been initiated
d. Antibiotic therapy was initiated 2 hr after implementation of the care pathway
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 post-term and is receiving oxytocin for labor induction
b. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion
c. A client who gave birth to her first child and requires instruction on breastfeeding techniques
d. A client who is 2 days postoperative following a caesarean birth and is having difficulty ambulating
18. A nurse is coordinating an inter-professional team to review proposed standards to reduce the transmission of MRSA. Which of the following members of the inter-professional team should the nurse consult?
a. Risk management coordinator
b. Nursing supervisor
c. Infection control nurse
d. Clinical pharmacist
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. Initiate a mental health consult to determine the client’s reasons for refusing surgery
b. Inform the client of the consequences of uterine prolapse and the need for intervention
c. Provide the client with information on treatment options and outcomes - check
d. Discuss with the client her concerns regarding the procedure
20. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?
a. Obtain telephone consent from the facility administrator before the surgery
b. Transport the client to the operating room without verifying informed consent
c. Delay the surgery until the nurse can obtain informed consent
d. Ask the anesthesiologist to sign the consent
21. A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to assistive personnel?
a. Informing a family of a client’s progress in physical therapy
b. Advising a client on self-administration of acetaminophen
c. Teaching a client to perform a finger-stick for testing blood glucose levels
d. Performing postmortem care prior to transferring the client to the morgue
22. A nurse is working on a quality improvement team that is assessing an increase in client 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. Identify clients who are at risk for falls
c. Review current literature regarding client falls
d. Implement a fall prevention plan
23. A nurse is completing a performance evaluation for 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 C. diff
b. The AP removes cut flowers from the room of a client who is in a protective environment
c. The AP wears a mask when caring for a client who has varicella
d. The AP closes the door of a client who is on airborne precautions
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. Demonstrate use of the pump during medication administration
b. Assess the staff nurses’ knowledge deficit
c. Pair an inexperienced nurse with an experienced nurse
d. Plan an in-service education program on the unit
25. A nurse is preparing a shift assignment for 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
b. Instruct a client to splint an abdominal incision
c. Check a client’s pain level 30 min after receiving acetaminophen
d. Collect a urine specimen from a newly admitted client
26. A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a client. Which of the following actions should the nurse take?
a. Provide treatment for minor injuries
b. Provide treatment for life-threatening injuries
c. Allow the client to die without further intervention
d. Treat the client’s injuries within 30 min
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’s electrical cord is taped to the floor
b. The client has used tacks to secure the carpet on the stairs
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
28. A charge nurse is observing a newly licensed nurse provide care for a client who has a C. diff infection. Which of the following actions by the newly licensed nurse indicates an understanding of proper infection control procedures?
a. Removes fresh flowers from the client’s room
b. Wears a gown when caring for the client
c. Washes her hands with an alcohol-based hand rub after caring for the client
d. Applies a mask before entering the client’s room
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 the tracheostomy at home? (Select all that apply.)
a. Petroleum jelly
b. Cotton balls
c. Obturator
d. Oxygen tank
e. Pipe cleaners
30. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent?
a. An adolescent client who is legally emancipated
b. An older adult client who has questions about the procedure
c. An adult client who has alcohol intoxication
d. An adult client who has moderate Alzheimer’s disease
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 should leave my valuables with a family member
b. I should remove my dentures before the procedure
c. I can wear my ankle bracelet since I am just having a local anesthetic
d. I can leave my wedding ring on if it is taped in place
32. A nurse is caring for an older adult client who has a Stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant?
a. Arrange for the wound care nurse specialist to see the client daily to provide the recommended treatment
b. Request the consultation after several wound care treatments are tried
c. Provide the consultant with subjective opinions and beliefs about the client’s wound care
d. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation
33. A nurse is observing assistive personnel (AP) administer a 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene?
a. Inserts the tubing 8 cm (3.1 in) into the rectum
b. Points tubing in the direction of the umbilicus during insertion
c. Positions the client on her left side with knees flexed
d. Administers the solution at room temperature
34. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
a. I can post the client’s vital signs in the client’s room
b. I should discard personal health information documents in the trash before leaving the unit
c. I should encrypt personal health information when sending emails
d. I can use another nurse’s password as long as I log off after using the computer
35. A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy?
a. ANA Standards of Practice
b. ANA Code of Ethics
c. State Nurse Practice Act
d. Institute of Medicine
36. A charge nurse observes a licensed practical nurse (LPN) 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
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. Establish work initiatives to promote a positive environment
b. Use root cause analysis to identify gaps in meeting standards
c. Compare practices within the facility against other high-performing facilities
d. Determine how current practice will affect future performance within the facility
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. Auscultate the client’s lungs
b. Notify the provider
c. Complete an incident report
d. Place a faulty equipment tag on the pump
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. You shouldn’t be worried because the procedure is very safe
b. This won’t take long and it will be over before you know it
c. Why did you make the decision to have this procedure?
d. It’s not too late to cancel the surgery if you want to
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. MRSA
b. Health care-acquired pneumonia
c. Lyme disease
d. Bacterial conjunctivitis
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 time the client received his last dose of pain medication
b. The belief that the client has a difficult relationship with his son
c. The client’s preferred time for bathing
d. The steps to follow when providing wound care
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. Document the prescription as a telephone prescription in the medical record
b. Ensure that the provider signs the prescription
c. Write down the complete prescription
d. Read back the prescription to the provider
43. A charge nurse witnesses assistive personnel (AP) falling to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first?
a. Alert the infection control department
b. Notify the unit manager about the incident
c. Reinforce facility protocols at the next staff meeting
d. Discuss the issue with the AP
44. A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan?
a. Remove the clock and calendar from the client’s room
b. Raise all four side rails on the client’s bed
c. Obtain a prescription for a sedative for the client
d. Provide distractions for the client during the day
45. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take?
a. Report the infection to the local health department
b. Instruct the client to use condoms until the treatment is completed
c. Initiate contact precautions
d. Apply an antiviral cream to lesions
46. A nurse is teaching a class of newly licensed nurses about evidence-based practice. The nurse should include which of the following as the first step in evidence-based practice?
a. Develop a clinical question
b. Collect evidence from a variety of sources
c. Apply research to client care practice
d. Critically assess the evidence
47. A nurse assumes the leading role on the hazardous materials team immediately following a chemical mass casualty incident in the community. As clients arrive at the designated triage area outside the hospital, which of the following actions should the nurse take?
a. Admit the injured clients to positive-pressure rooms
b. Place shower caps over the clients’ hair
c. Scrub the clients’ skin with betadine solution
d. Remove contaminated clothing
48. A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred?
a. Slander
b. Negligence
c. Battery
d. Libel
49. A nurse is preparing to complete morning assessments on several assigned clients. Which of the following clients should the nurse plan to assess first?
a. A client who had a bladder scan that indicated 250 mL of urine in the bladder
b. A client who is 3 days postoperative and whose 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
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. I will need to notify the client’s provider about this breach of confidentiality
c. We should discuss your concerns with the client’s care team
d. Do you understand the HIPAA regulations?
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 1.3 cm (0.5 in) away from the edge of a sterile drape
b. Uses a sterile-gloved hand to adjust the back of the sterile gown
c. Sets up the sterile field 30 min prior to performing the dressing change
d. Uses sterile forceps to pack sterile gauze into the wound
52. A nurse working in a long-term care facility is assessing an older adult client who has been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the following actions should the nurse take?
a. Perform hand hygiene with alcohol-based hand sanitizer
b. Place the client in a negative-pressure airflow room
c. Clean the equipment in the client’s room with bleach
d. Initiate droplet precautions for the client
53. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?
a. Ask other staff members to take over some of his tasks
b. Offer to provide care for his clients while he takes a break
c. Recommend that he take time to plan at the beginning of his shift
d. Advise him to complete less time-consuming tasks first
54. A nurse is planning discharge for a client who had a lung resection. The nurse initiates a referral for a social worker. Which of the following assessment data supports this referral?
a. The client needs to have someone come in to help her bathe at home
b. The client needs to arrange financial resources to purchase equipment
c. The client needs to have someone bring oxygen tanks and equipment to her home
d. The client needs to have range-of-motion exercises to assist with ambulation
55. A nurse initiates a referral to an occupational therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for this referral?
a. The client requires assistance with completing oral hygiene
b. The client reports pain when chewing solid foods
c. The client has difficulty ambulating with a walker
d. The client expresses the desire to join a support group
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. Mental health counselor
b. Physical therapist
c. Occupational therapist
d. Case manager
e. Nutritional therapist
57. 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 feeling lightheaded when he stands up from a lying position
b. A client who reports an urge to void but has not urinated during the prior shift
c. A client who reports a headache with sensitivity to light
d. A client who reports indigestion and pain in her jaw - check
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 bipolar disorder and displays constant pacing
b. A client who has schizophrenia and uses neologisms
c. A client who has depressive disorder and has poor personal hygiene
d. A client who has dementia and exhibits aphasia
59. A nurse is planning care for a group of clients. Which of the following actions should the nurse take first?
a. Obtain a breakfast tray for a client whose total parenteral nutrition was discontinued 4 hr ago
b. Auscultate the bowel sounds of a client who has not had a bowel movement after taking a laxative 12 hr ago
c. Check a client who has a leg cast and reports a new onset of pain - check
d. Provide instruction to the caregiver of a client who has dementia and a new diagnosis of diabetes mellitus
60. A nurse on a medical-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make?
a. You should appoint a health care proxy before undergoing an invasive procedure
b. You must choose a member of your family to serve as your health care proxy
c. A health care proxy can make decisions for you when you are unable to do so
d. It is necessary for an attorney to approve your health care proxy
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. Review the intended purpose of the prescribed medications with the client
c. Compare the client’s medication administration record with the prescriptions on the transfer orders
d. Call the provider to clarify the client’s prescribed medications
62. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?
a. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy
b. A client who is postoperative following a laminectomy 12 hr ago and is unable to void
c. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
d. A client who has MRSA and has an axillary temperature of 38 C (101 F)
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. Place a surgical mask on the client during transfer to the unit
c. Prepare to administer antibiotics to the client
d. Wear an N95 respirator mask while caring for the client
64. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
a. Determine the reasons the nurses are not taking scheduled breaks
b. Review facility policies for taking scheduled breaks
c. Discuss time management strategies with the nurses
d. Provide coverage for the nurses’ 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. Battery
b. False imprisonment
c. Libel
d. Assault
66. A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit. Which of the following responses by the nurse is appropriate?
a. Please ask your relative about this, because I cannot share information about her
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. I’m not taking care of your relative today, so I don’t have the latest information
67. A nurse suggests respite care for the partner of a client who has mild cognitive impairment. The client’s partner asks the nurse how that would help. The nurse should explain that respite care would do which of the following?
a. Send a clinician to assess the safety of leaving her partner alone
b. Allow her to take time off from attending to her partner
c. Help her arrange transferring her partner to an assisted living facility
d. Provide volunteers who will run errands for her
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. Nonmaleficence
b. Fidelity
c. Veracity
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. Review the risks and benefits of the procedure with the client
b. Assess the client’s understanding after the provider has talked with her
c. Discuss alternative treatment options with the client
d. Place a photocopy of the signed informed consent in the client’s medical record
70. A nurse is providing teaching to assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?
a. Secure the client’s restraints with a square knot
b. Remove the client’s restraints every 2 hr
c. Attach the restraints to the fixed portion of the frame of the client’s bed
d. Allow 1 fingerbreadth between the restraint and the client’s wrists [Show Less]