Detailed Answer Key
Leadership Practice ATI
1. A nurse is transcribing a client’s medication prescriptions and is having difficulty reading a written
... [Show More] prescription by
the provider. Which of the following nursing actions should the nurse take?
A. Clarify the prescription with the client’s family.
Rationale: The nurse should not clarify the medication prescription with the client’s family, because this
action could be a breach of confidentiality.
B. Interpret the prescription based on the client’s health history.
Rationale: The nurse should not interpret the medication prescription based on the client’s health history,
because incorrect information may result.
C. Ask the pharmacist for clarification of the prescription.
Rationale: The nurse should not ask the pharmacist for clarification of the prescription, because incorrect
information may result.
D. Contact the provider to clarify the prescription.
Rationale: The nurse should contact the provider for clarification of the prescription to confirm the correct
interpretation of the prescription.
2. A nurse on a quality control committee is evaluating the results of recently implemented measures designed to
reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the
changes?
A. Establish a benchmark to identify a standard of performance.
Rationale: A benchmark measures the practices of an organization against a best–performing organization
in order to develop improvement of performance. It is used as a tool to determine the desired
standard of performance.
B. Compare the number of medication errors before and after the action was implemented.
Rationale: Preimplementation and postimplementation statistics for medication errors will provide
information to determine the success of the actions.
C. Provide the staff with a questionnaire to quantify staff satisfaction with the changes.
Rationale: A questionnaire that determines staff satisfaction can provide a means of communication
regarding the new practice, but it does not measure the success of the new measures.
D. Conduct a study about the time and money costs of implementing the change.
Rationale: A study about the time and money costs of the effort is useful for comparing the success of the
changes to the cost required to make them. However, this will not measure how successful the
changes were in reducing medication errors.
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3. A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the
following assignments is an example of overdelegation?
A. Assigning two assistive personnel (AP) to ambulate all clients
Rationale: Assigning two APs to ambulate 10 clients follows the rights of delegation and expectations of the
APs. It is not an example of overdelegation.
B. Assigning a new graduate nurse to perform a wet-to-dry dressing change
Rationale: Assigning a new graduate nurse to perform a wet-to-dry dressing change follows the rights of
delegation and expectations of the nurse. It is not an example of overdelegation.
C. Assigning the most efficient AP to perform glucometer monitoring for each client
Rationale: Asking the most efficient AP to perform glucometer testing based on her efficiency in performing
this task is an example of overdelegation. This can result in the AP becoming overworked and
tired, thus decreasing productivity.
D. Assigning the most competent RN to perform a central line dressing change
Rationale: Assigning the most competent RN to perform a central line dressing change follows the rights of
delegation and expectations of the nurse. It is not an example of overdelegation.
4. A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most
from the nurse acting as an advocate?
A. A client who has previously undergone a procedure that is to be performed for a second time
Rationale: The nurse supports the client in this situation, but it is not an example of a client benefitting most
from the nurse acting as an advocate.
B. A client who has been educated on treatment options and chooses alternative treatments
Rationale: The nurse supports the client in this situation, but it is not an example of a client benefitting most
from the nurse acting as an advocate.
C. A client who makes an informed decision not to participate in chemotherapy treatment
Rationale: The nurse supports the client in this situation, but it is not an example of a client benefitting most
from the nurse acting as an advocate.
D. An older adult client who has no family and is uncertain about moving to assisted living
Rationale: The nurse acts as an advocate by ensuring the client has correct information to make an
appropriate decision in selecting needed services. This is an example of a client benefitting
most from the nurse acting as an advocate.
5. A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and
time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which
of the following persons should sign the informed consent?
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Leadership Practice ATI
A. The client's partner
Rationale: Legal decisions regarding health care must be made by a competent person or the person
holding the durable power of attorney.
B. The client
Rationale: If the client appears competent, and understands the procedure, the client can sign for informed
consent. The nurse should verify that the client gives consent voluntarily, the signature on the
consent is the client's, and the client appears competent. If the client were disoriented and not
competent, the person who has durable power of attorney should sign informed consent.
C. The client's daughter, who is the primary caregiver
Rationale: Although the primary caregiver cares for the client, legal decisions regarding health care must
be made by a competent person or the person holding the durable power of attorney. Caring for
a client does not give the client's daughter legal authority regarding health care decisions.
D. The client's son, who has a durable power of attorney
Rationale: A durable power of attorney for health care is a legal document that designates an individual
authorized to make health care decisions for a client who is unable. The client's son should be
familiar with the client's wishes.
6. A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several
bruises in various stages of healing. The client and family member explain that the bruises are a result of
clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following
actions should the nurse take first?
A. Document the bruises in the client's chart.
Rationale: The nurse should document the bruises in the client’s chart after providing care to comply with
legal guidelines; however, there is another action the nurse should take first.
B. Report the findings to a supervisor.
Rationale: The greatest risk to this client is further injury from continued abuse; therefore, the first action
the nurse should take is to report the findings to a supervisor. Nurses are required to report
suspected cases of child and older adult abuse.
C. Provide the client with a crisis hotline number.
Rationale: The nurse should provide the client and family with a crisis hotline number in case emergency
help is needed; however, there is another action the nurse should take first.
D. Discuss respite care with the client’s family.
Rationale: The nurse should discuss respite care with the client’s family to prevent caregiver role strain;
however, there is another action the nurse should take first.
7. A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following
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tasks should the nurse delegate to the LPN? (Select all that apply.)
A. Provide discharge instructions to a confused client's spouse.
B. Obtain vital signs from a client who is 6 hr postoperative.
C. Administer a tap-water enema to a client who is preoperative.
D. Initiate a plan of care for a client who is postoperative from an appendectomy.
E. Catheterize a client who has not voided in 8 hr.
Rationale: Providing discharge instructions to a confused client's spouse is incorrect. The nurse is
responsible for delegating a task to the person who has proper training and skill. Client
education is the responsibility of the registered nurse.Obtaining vital signs from a client who is 6
hr postoperative is correct. Obtaining is a task that is appropriate to the education and skills of
an LPN.Administering a tap-water enema to a client who is preoperative is correct.
Administering a tap-water enema is a task that is appropriate to the education and skills of an
LPN.Initiating a plan of care for a client who is postoperative from an appendectomy is incorrect.
Planning care is the responsibility of the registered nurse.Catheterizing a client who has not
voided in 8 hr is correct. Urinary catheterization is a task that is appropriate to the education and
skills of an LPN.
8. A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following
actions should the nurse take?
A. Inform the staff member of her appraisal time for that day prior to change-of-shift report.
Rationale: The charge nurse should give the employee 2 to 3 days advance notice of the appraisal
conference time so the staff member can be prepared for the interview.
B. Schedule the appraisal interview as early in the shift as possible.
Rationale: The charge nurse should schedule the appraisal interview at a time when it is not busy at work
and when it is convenient for the staff member so she can have time to fully participate in the
conference.
C. Provide a chair directly across the desk for the staff member to sit in.
Rationale: The charge nurse should arrange the chairs so they are side by side to denote collegiality.
Placing the chairs across from one another denotes a power status position.
D. Provide the staff member with a copy of the appraisal form in advance.
Rationale: The charge nurse should ensure the staff member knows the standards by which her work will
be evaluated and that she has a copy of the appraisal form.
9. A nurse has completed an informed consent form with a client. The client then states, “I have changed my mind and
do not want to have the procedure done.” Which of the following actions should the nurse take?
A. Remind the client that a signed informed consent form is a legally binding document.
Rationale:
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The client has the right to withdraw informed consent; therefore, informing the client the consent
is a legal document is not an appropriate response.
B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure.
Rationale: The client has the right to withdraw informed consent; therefore, the surgeon who is the one to
obtain the informed consent should be notified of the request.
C. Inform the surgical team to cancel the client’s surgery.
Rationale: The client has the right to withdraw informed consent; however, the surgeon who is the one to
obtain the informed consent should be notified first to determine if the surgery will be cancelled.
D. Proceed with preparation of the patient for the surgical procedure.
Rationale: The client has the right to withdraw informed consent; therefore, proceeding with the preparation
for surgery is not an appropriate response.
10.A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks.
The nurse is demonstrating which of the following rights of delegation?
A. Right circumstances
Rationale: The right circumstances include delegating tasks that do not require independent nursing
judgment.
B. Right communication
Rationale: The right communication includes providing clear explanations about the tasks, client
outcomes, and when the delegate should report to the nurse.
C. Right person
Rationale: The right person means delegating to the individual who is competent and qualified.
D. Right supervision
Rationale: The nurse is demonstrating the right supervision when she assesses how the tasks are being
accomplished and if any improvements are needed.
11.A nurse intercepts a messenger at the nurses’ station who has a flower delivery for a client on the unit. As the
nurse accepts the flowers, the messenger says, “I know Mrs. Welch from the neighborhood. What happened to
her?” Which of the following responses should the nurse provide?
A. “You know it’s not appropriate for you to ask me that.”
Rationale: This is a nontherapeutic automatic response that assumes that the messenger has knowledge
of client confidentiality. This response belittles the messenger and minimizes his concerns.
B. “It’s my responsibility to remind you that we have to respect our clients’ privacy.”
Rationale:
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This therapeutic response provides clarification to the messenger that the hospital staff cannot
disclose information about clients.
C. “It’s a minor injury. I’m sure you’ll see her back in the neighborhood soon.”
Rationale: This is a nontherapeutic response. The nurse may not provide health information about a client
to anyone other than hospital staff who are directly involved in the client’s care. Sharing of
information about a client violates the client’s right to privacy and confidentiality.
D. “Oh, what lovely flowers. She will enjoy these.”
Rationale: This is a nontherapeutic response which changes the subject, does not address the
messenger’s concerns and offers the nurse’s personal opinion about the client’s enjoyment of
the flowers.
12.A nurse enters a client’s room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR)
order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?
A. Call the emergency response team.
Rationale: Unless the provider writes a DNR order, the nurse should make every effort to revive the client.
The nurse should follow the facility’s protocol for enacting the emergency response procedure.
B. Seek immediate help from the risk manager.
Rationale: The nurse does not have time to wait for a response from the risk manager. The nurse should
follow the facility’s protocol for this type of situation.
C. Call the provider for a stat DNR order.
Rationale: The nurse should follow the facility’s protocol for this type of situation.
D. Respect the family’s wishes and do nothing.
Rationale: The nurse should follow the facility’s protocol for this type of situation. Without a DNR order, the
nurse cannot follow the family’s wishes.
13.A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication
to a competent client after the client has refused it is an example of which of the following torts?
A. Assault
Rationale: Assault is the act of verbally threatening a client. A nurse who verbally threatens to give a
medication to a client without the client’s consent is committing assault.
B. False imprisonment
Rationale: False imprisonment is detaining a client against her will without legal warrant. A nurse who
administers a chemical restraint without the client’s consent is committing false imprisonment.
C. Negligence
Rationale:
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Negligence is a breach of duty that results in harm to the client. A nurse who administers an
incorrect medication to a client is committing professional negligence.
D. Battery
Rationale: Battery is physical contact without the client’s consent. Administering a medication against a
client’s wishes is an example of battery.
14.A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge
nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating
which of the following types of conflict management?
A. Avoiding
Rationale: The charge nurse did not display avoiding, which is not to acknowledge or try to resolve the
conflict.
B. Competing
Rationale: The charge nurse did not display competing, which is when one person makes a quick or
unpopular decision at the expense of another.
C. Compromising
Rationale: The charge nurse did not display compromising, which is when all parties involved are willing to
give up something in the resolution of the conflict.
D. Cooperating
Rationale: The charge nurse displayed cooperating, which is the resolution of the conflict by sacrificing. In
this situation, it allowed both staff nurses to get what they wanted.
15.A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on
the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of
change?
A. Assess the problem.
Rationale: During the unfreezing stage, the charge nurse should assess the problem.
B. Use tactics to alert staff nurses that a change is needed.
Rationale: During the unfreezing stage, the charge nurse should make the staff nurses aware that a
change is needed.
C. Evaluate the effectiveness of the change.
Rationale: During the refreeze stage, the charge nurse should evaluate the effectiveness of the change.
D. Set a target date.
Rationale:
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During the moving stage, the charge nurse should develop the plan for change and set the
target date.
16.A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative
following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a
pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy
tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the
nurse plan to complete first?
A. Weigh the second client.
Rationale: The nurse should weigh a client at the same time daily, but this is not the first action that the
nurse should take.
B. Obtain vital signs for both clients.
Rationale: Using the nursing process as an organizing framework, the nurse should obtain vital signs on
the two clients to determine if there are any emergent problems.
C. Administer pain medication to the first client.
Rationale: The nurse should complete a client assessment prior to administering pain medication.
D. Change the dressings of both clients.
Rationale: When obtaining vital signs, the nurse should also examine the condition of the dressing for
signs requiring immediate action. Routine dressing changes are not the nurse’s priority action.
17.A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse
should recognize that the float nurse is most qualified to care for which of the following clients?
A. A client who is postoperative following a lobectomy and has a chest tube
Rationale: According to evidenced-based practice, the nurse from the PACU is most qualified to care for
the postoperative client. Nurses in the PACU care for clients with chest tubes after surgery.
This is the right client, the right task, and the right circumstances for this nurse.
B. A client who is being discharged to a long-term care facility
Rationale: The nurse should be capable of caring for this client. However, there is another client the nurse
is more qualified to care for. A nurse who works in the PACU might not be familiar with the
policy or procedure for a discharge to a long-term care facility. Since a report is given to the
receiving facility, it is better to assign a nurse who is familiar with the client and their treatment.
The five rights of delegation are not met with this client.
C. A client who needs teaching about insulin self-administration
Rationale: The nurse should be capable of caring for this client. However, there is another client the nurse
is more qualified to care for. Though all nurses are familiar with proper injection techniques
and teaching, this is not a practice that a nurse in the PACU routinely participates in and is not
the best assignment for the nurse. The five rights of delegation are not met with this client.
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D. A client who needs teaching prior to initiating cardiac rehabilitation activities
Rationale: The nurse should be capable of caring for this client. However, there is another client the nurse
is more qualified to care for. Although this nurse should understand the concepts of cardiac
rehabilitation, the PACU does not offer the opportunity to care for clients who require these
services. The five rights of delegation are not met with this client.
18.A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch.
Which of the following actions should the nurse take?
A. Counsel the provider to determine the cause of the substance abuse.
Rationale: The responsibility of the nurse is to protect clients from injury. It is not the responsibility of the
nurse to counsel the provider.
B. Encourage clients to change to a different provider.
Rationale: Encouraging clients to change services based on assumptions is defamation and could result
injury to the reputation of the provider. The nurse could be sued for this action.
C. Inform the state medical board for an immediate investigation.
Rationale: It is the responsibility of hospital management and administration to follow up with any state
licensure boards in cases of impairment or client negligence or harm.
D. Notify the nursing supervisor of the concerns.
Rationale: The nurse should notify hospital or nursing management of the concerns, and then ensure
client safety. It is the responsibility of management to conduct an investigation. Client safety is
the responsibility of the nurse.
19.A nurse manager is reviewing information about critical pathways with the unit nurses. Which of the following
information should the nurse manager include?
A. "Critical pathways should include evidence-based interventions."
Rationale: Research evidence indicates that standardized care backed by evidence based practice
improves client outcomes. Therefore, the critical pathway should be created using
evidence-based interventions and treatment.
B. "Critical pathways replace nursing care plans."
Rationale: Critical pathways are multidisciplinary and do not include detailed nursing interventions;
therefore, they do not replace nursing care plans.
C. "Critical pathways are used for clients who have rare medical diagnoses."
Rationale: Critical pathways are developed for clients who have common medical diagnoses, such as
heart failure.
D. "Critical pathways reduce the amount of paperwork involved in client care."
Rationale:
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Critical pathways increase the amount of paperwork involved in client care, but are still viewed
as being advantageous because they improve client care and decrease the cost of care.
20.A nurse on a pediatric unit is caring for four clients. The nurse should recommend an interdisciplinary client care
conference for which of the following clients?
A. A client who was diagnosed with cystic fibrosis and has a distended abdomen.
Rationale: Cystic fibrosis is a genetic disease that requires the management of respiratory,
gastrointestinal, and endocrine problems. A multidisciplinary approach is needed to promote
quality of life for this client.
B. A client who is 10 hr postoperative from an appendectomy.
Rationale: Recovery from an appendectomy is usually rapid and without complications; therefore, the
nurse should not recommend an interdisciplinary conference for this client.
C. A client who is 6 hr postoperative from a tonsillectomy.
Rationale: Although the client is at risk for bleeding following the procedure, most clients recover fully in
1-2 weeks. Therefore, the nurse should not recommend an interdisciplinary conference for this
client.
D. A client who was diagnosed with acute diarrhea from the Norovirus.
Rationale: Acute diarrhea from the Norovirus is usually self-limiting. Therefore, the nurse should not
recommend an interdisciplinary conference for this client.
21.A nurse is applying wrist restraints to a client who is confused and attempting to pull out a chest tube. Which of the
following actions should the nurse taking when using restraints?
A. Ensure that 1 finger breadth of space is between the client’s wrists and the restraint.
Rationale: The nurse should ensure that there are 2 finger breadths of space between the client’s wrists
and the restraints.
B. Secure the restraints to the side rails.
Rationale: The nurse should tie the restraints to a part of the bed frame that moves when the head of the
bed is raised or lowered.
C. Remove the restraint to check integrity of the skin every 4 hr.
Rationale: The nurse should remove the restraints at least every 2 hr to check the integrity of the skin.
D. Tie the restraint using a quick release knot.
Rationale: The nurse should use a half bow (clove hitch, quick release) knot that does not does not tighten
and can be removed quickly.
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22.A nurse is interviewing a female client who is Hispanic. The client's partner answers the questions and states,
"She speaks only a little English." Which of the following actions should the nurse take?
A. Arrange to complete the assessment with only the client and a translator present.
Rationale: As a client advocate, the nurse should provide a trained interpreter to translate for the client. It
is critical to obtain assessment information directly from the client in order to protect the client's
personal health information and collect an accurate history.
B. Ask the client's partner to translate questions and answers for the client.
Rationale: The nurse should not use a family member as an interpreter for the client. This option does not
demonstrate advocacy for the client because it does not protect the client's confidentiality. The
client might not wish the family member to know about her health history and does not ensure
that accurate information is obtained.
C. Ask a male student nurse to translate for the client.
Rationale: Unless the student nurse is trained as an interpreter, he should not interpret for the client. The
client might feel embarrassed using a male interpreter.
D. Use an internet website ending in.com to translate for the client.
Rationale: An internet website ending in.com is a commercial website and can contain inaccurate
information. This should not be used to translate an assessment history for a client.
23.A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain
injury. Which of the following information should the nurse include in the background segment of SBAR?
A. Glasgow results
Rationale: The nurse should include the Glasgow coma scale under the assessment segment of SBAR.
B. Intracranial pressure readings
Rationale: The nurse should include intracranial pressure readings under the assessment segment of
SBAR.
C. Code status
Rationale: The nurse should report the client’s current code stats in the background segment of SBAR.
D. Plan of care changes for upcoming shift
Rationale: The nurse should include any changes to the plan of care for the next shift under the
recommendation segment of SBAR.
24.A community health nurse is reviewing information about infectious diseases with the nurses on her team. The
nurse should remind the team that which of the following diseases are included in the list of nationally notifiable
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infectious diseases? (Select all that apply.)
A. Trichomonas vaginalis
B. Chlamydia
C. Gonorrhea
D. Chancroid
E. Candidiasis albicans
Rationale: Trichomonas vaginalis is a sexually transmitted infection that occurs in women more often than
men, but it is not on the list of nationally notifiable infectious diseases.
Chlamydia is a sexually transmitted infection. When a client is diagnosed with chlamydia, the
public health department is notified so that sexual partners can be notified and treated.
Gonorrhea is a sexually transmitted infection. When a client is diagnosed with gonorrhea, the
public health department is notified so that sexual partners can be notified and treated.
Chancroid is a sexually transmitted infection. When a client is diagnosed with chancroid, the
public health department is notified so that sexual partners can be notified and treated.
Candidiasis albicans is a yeast infection which can affect the vagina, but it is not on the list of
nationally notifiable infectious diseases.
25.A nurse is receiving a provider’s prescription for a client via telephone. Which of the following actions should the
nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)
A. Repeat the order back to the provider.
B. Question any part of the order that is unclear or inappropriate.
C. Transcribe the order into the client’s health record.
D. Obtain the provider’s signature within 8 hr.
E. Implement a recorded order message if the nurse can hear and understand it clearly.
Rationale: Repeat the order back to the provider is correct. The nurse should read the order back and
have the provider verbally confirm that it is correct.Question any part of the order that is unclear
or inappropriate is correct. The nurse should question any part of the prescription or an order
that is unclear or inappropriate. This is essential for any verbal or written prescription or
order.Transcribe the order into the client’s health record is correct. The prescription should be
entered in the health record as it is obtained and verified.Obtain the provider’s signature within
8 hr is incorrect. Although the policy may vary with each facility, the usual rule is to obtain the
provider’s signature within 24 hr.Implement a recorded order message if the nurse can hear
and understand it clearly is incorrect. If a provider leaves a recorded order message, the nurse
should call the provider and obtain the prescription verbally over the telephone.
26.A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider
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care for immediately?
A. An adolescent female client who is belligerent and has slurred speech
Rationale: This client is displaying the effects of excessive alcohol intake and needs care. However, there
is another client who has a higher priority need and should be cared for by the provider first.
B. A toddler who has a laceration on his forehead and is screaming
Rationale: The nurse should apply pressure to the site of laceration and work with the parent to decrease
the toddler’s anxiety. However, there is another client who has a higher priority need and
should be cared for by the provider first.
C. A middle adult male who is diaphoretic and reports epigastric pain
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that
caring for this client is the highest priority because diaphoresis and epigastric pain are
manifestations of an acute myocardial infarction.
D. A young adult with a painful sunburn of his face and arms
Rationale: A sunburn is a superficial burn and the client needs to be cared for by the provider. However,
there is another client who has a higher priority need and should be cared for by the provider
first.
27.A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following
client goals the priority?
A. Attain a weight that is greater than the 75th percentile for age and height.
Rationale: When using Maslow’s hierarchy of needs, the nurse should determine the priority goal is to
meet the physiological need for adequate nutrition. This means working with the client to attain
an increase in weight.
B. Make positive statements about improvements in body image.
Rationale: Making positive statements about improvement in body image is important because the client
needs to attain positive self-esteem; however, there is another goal that is the priority.
C. Feel in control of her behavior.
Rationale: Having the client feel she is in control of her behavior is important because the client needs to
attain the goal of safety; however, there is another goal that is the priority.
D. Identify changes within the family unit that promote the client’s autonomy.
Rationale: The client needs to identify changes that promote autonomy because it is important for the
client to attain the goal of love and belonging; however, there is another goal that is the priority.
28.A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the
clients. Which of the following clients is the nurse’s priority?
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A. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his
post-meal capillary blood glucose is now 160 mg/dL
Rationale: Both blood glucose levels are within the expected reference range. This client is stable;
therefore, he is not the nurse’s priority.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
Rationale: A change in the color of wound drainage from sanguineous to serosanguineous is an expected
finding for a client who is 24 hr postoperative from surgery. Therefore, this client is not the
nurse’s priority.
C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
Rationale: The nurse should ask the client to rate his pain on a scale of 0 to 10 and provide care to
manage the client’s pain. However, this client is not the nurse’s priority.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
Rationale: A client who is postoperative is at risk for hemorrhage. A blood pressure decrease of 15 to 20
points is significant. This client is unstable; therefore, this client is the nurse’s priority.
29.A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff
following this incident?
A. Provide professional counseling for staff members.
Rationale: This is an appropriate intervention. However, it is not the priority when taking the nursing
process approach to client care, as assessment of staff should be done before providing
counseling.
B. Change policies for staff observation of clients who are suicidal.
Rationale: This is an appropriate intervention. However, it is not the priority when taking the nursing
process approach to client care. An analysis of current policies needs to be done before
changes are made.
C. Identify cues in the client’s behavior that might have warned them that he was contemplating suicide.
Rationale: Identifying cues in the client’s behavior is the priority intervention when taking the nursing
process approach to client care. Assessment is the first step in dealing with a situation.
D. Give the family an opportunity to talk about their feelings.
Rationale: Rationale D. This is an appropriate intervention. However, it is not the priority when taking the
nursing process approach to client care. The family needs ongoing opportunities to process
their feelings.
30.A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention.
Which of the following actions is the nurse's priority?
Created on:03/25/2019 Page 14Detailed Answer Key
Leadership Practice ATI
A. Instruct the client about home disposal of contaminated dressings.
Rationale: The nurse should instruct the client about home disposal of contaminated dressings to reduce
the risk of spreading potentially infectious material to the environment or to others. However,
another action is the priority.
B. Schedule a follow-up visit by a home health nurse for dressing changes.
Rationale: The greatest risk to this client is injury from a wound infection. Therefore, the priority action the
nurse should take is to schedule a follow-up visit by a home health nurse for dressing changes.
Wounds healing by secondary intention are open and have edges that are not approximated,
which increases the risk for infection.
C. Provide a dietary list of foods which promote wound healing.
Rationale: The client is at risk for impaired wound healing due to inadequate nutrition. However, another
action is the priority. Adequate nutritional intake will promote wound healing. The client's diet
should include foods high in fluids, protein, vitamin A, vitamin C, and zinc.
D. Establish a follow-up appointment with the client's provider.
Rationale: The nurse should schedule a follow-up appointment with the client's provider to monitor the
client and assess healing. However, another action is the priority. [Show Less]