ATI RN Leadership Management 2019 Retake Guide
1. A nurse is evaluating a newly licensed nurse who is administering a vitamin K injection to a newborn.
... [Show More] Which of the following actions by the newly licensed nurse indicates understanding of the teaching? (SATA)
a. Applies gentle pressure at the site after injection
b. Aspirates the syringe for blood return after needle insertion
c. Selects the dorsogluteal site to administer the injection
d. Inserts the needle at a 45° angle - IM should be 90
e. Cleans the injection site with alcohol
Rationale: https://www.atitesting.com/ati_next_gen/skillsmodules/content/medication-administration- 3/equipment/intramuscular-injections.html
2. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective?
a. “Guardian consent is required for an emancipated minor.”
b. “Consent can be given by a durable power of attorney.”
c. “The nurse can answer any questions the client has about the procedure.”
d. “A family member can interpret to obtain informed consent from a client who is deaf.”
3. 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. Obtain the blood sample from the finger pads.
b. Elevate the arm for 1 min before taking the blood sample.
c. Cap the lancet prior to putting it in the trash.
d. Warm the hands prior to piercing the skin
4. A client is admitted with COPD. Which of the following findings should the nurse report to the provider?
a. Report of dyspnea on exertion
b. Oxygen saturation 89% on room air
c. White blood cell count 9,000/mm3
d. Bilateral crackles on auscultation of lungs
5. A client schedule 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.”
6. 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. Libel
b. False imprisonment
c. Battery
d. Assault
7. A nurse manager overhears a provider and a staff nurse talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first?
a. Provide a staff inservice about client confidentiality.
b. Fill out an incident report regarding the situation.
c. Remind them that client information is confidential.
d. Report the incident to the nursing supervisor.
8. A nurse is serving on a committee that is revising the protocol for discharging clients. After developing an initial plan, in which order should the nurse take the following steps?
• Determine goals
• Implement recommended strategies
• Revise the plan.
• Evaluate the results
9. A nurse is orienting to an emergency department. The nurse is asked to assist with suturing of a laceration on a client’s hand. Which of the following is the best resource for this nurse?
a. The preceptor on the clinical unit
b. The provider suturing the client’s injury
c. The nursing supervisor
d. The information on the suture package
10. A client is brought to the emergency department (ED) following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse?
a. Assess the client for urinary retention.
b. Obtain a provider‟s prescription for a blood alcohol level.
c. Tell the client that a catheter will be inserted.
d. Document the client’s refusal in the chart.
11. 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. Ask nurses who are caring for clients without this information in the medical record to obtain it.
b. Remind nurses to obtain this information during the admission process.
c. Meet with nursing staff to review the policy regarding advance directives.
d. Reinforce the potential consequences of not having this information on record to the nursing staff.
12. 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. Determine client care goals.
b. Review the client’s new laboratory values.
c. Complete required tasks.
d. Document assessment data.
13. A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?
a. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min.
b. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.
c. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better.
d. A nurse explains to a client’s family that a DNR includes withholding comfort measures.
14. A nurse is caring for a client who is unconscious and whose partner is his health care proxy. The partner has spoken with the provider and wishes to discontinue the client’s feeding tube. The provider states to the nurse, “I will not discontinue this client’s treatment. His partner has no right to make decisions regarding the client’s care.” Which of the following responses by the nurse is appropriate?
a. “We’ll need to have the nursing supervisor review the client’s advance directives.”
b. “You should consider speaking with the facility’s ethics committee before making your decision.”
c. “You have the right to make that decision, even if the partner is the client’s health care proxy.”
d. “The client has designated his partner as health care proxy in his advance directives.”
15. 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
16. A nurse is preparing to discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the following information should the nurse include in the verbal transfer report?
a. Laboratory results within the expected reference range
b. Level of consciousness
c. List of regularly prescribed medications
d. Date of last bowel movement
17. A charge nurse on a postpartum unit is teaching a client who gave birth 2 hr ago about the facility‟s protocols for preventing newborn abduction. Which of the following instructions should the nurse include?
a. “Carry your baby snugly in your arms whenever you leave your room.”
b. “Make sure to leave your baby in the bassinet by your bed when you use the bathroom.”
c. “Keep your baby next to you in your bed if you think you might fall asleep.”
d. “Check the photo identification badge of staff members who care for you and your baby.”
18. A nurse is assigned the following four clients for the current shift. Which of the following clients should the nurse assess first?
a. A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot
b. A client who has a hip fracture and is in Buck‟s traction
c. A client who has aspiration pneumonia and a respiratory rate 28/min ABC
d. A client who has a Clostridium difficile infection and needs a stool specimen collected
19. A nurse should recognize that an incident report is required when
a. A visitor pinches his finger in the client’s bed frame.
b. A nurse gives a medication 30 min late.
c. A client throws a box of tissues at a nurse.
d. A client refuses to attend physical therapy.
20. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practical nurse?
a. Referring a client to social services for assistance with transportation
b. Providing the first oral feeding to a client following a stroke
c. Instructing a client who is obese about a low-fat diet
d. Changing the dressing on a postoperative wound
21. A nurse is precepting a newly licensed nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurse ask?
a. “Are you removing the client’s restraints every 4 hours?”
b. “Are you able to insert two fingers between the restraints and the client’s skin?”
c. “Did you tie the restraints using a double knot?”
d. “Did you secure the restraints to the side rails of the bed?”
22. A nurse observes a paper bag at the bedside of a client. This finding suggests that the client is receiving treatment for which of the following respiratory disorders?
a. Stridor
b. Asthma
c. Hyperventilation
d. Atelectasis
23. Which of the following observations requires a charge nurse to intervene and demonstrate safe handling techniques?
a. A nurse uses goggles to perform tracheostomy suctioning.
b. A nurse places a mask on a client with tuberculosis before transport to the radiology department.
c. A nurse cleans up a blood spill with a 1:10 bleach solution.
d. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen.
24. A nurse preceptor is evaluating a newly licensed nurse‟s competency in assisting with a sterile procedure. Which of the following actions indicates the nurse is maintain sterile technique? (SATA)
a. Opens the sterile pack by first unfolding the flap farthest from her body
b. Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field
c. Places sterile items within a 1.25-cm (0.5-inch) border around the edges of the sterile field
d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
e. Rests the cap of a solution container upside down on the sterile field
25. A nurse working on a medical-surgical unit is receiving shift report regarding four clients. Which of the following client should the nurse see first?
a. A 75-year-old man who has pneumonia and has a O2 saturation of 92%
b. A 80-year-old woman who has a urinary tract infection and a temperature of 38.2° C (100.8° F)
c. A 45-year-old man who has new onset of confusion 24 hr after a total hip arthroplasty [Show Less]