Notesale: Turn your study into money

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LEADERSHIP
1
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3
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5
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7
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9
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Drug use is suspected in
the crash, and a voided urine specimen is ordered
...

Which of the following is the appropriate action by the nurse?
a
...

b
...

c
...

d
...

A nurse is making shift assignments in a hospital
...
Pick up the meal trays after lunch
...
Administer a nasogastric tube feeding
...
Plan break times for assistive personnel
...
Determine adequacy of ventilator settings
...

Which of the following actions indicates the newly licensed nurse is maintaining sterile technique? (SATA)
a
...
25 cm (0
...
Opens the sterile pack by first unfolding the top flap away from her body
c
...
Removes the outside packaging of a sterile instrument before dropping it onto the sterile
field
e
...
Which of the following actions should the nurse take first?
a
...

b
...

c
...

d
...

A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and
an assistive personnel
...
Reinforcing teaching with a client who is learning to self-administer insulin
b
...
Administering morphine IV bolus to a client who is __ hr postoperative
d
...
After donning a sterile
gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic
technique?
a
...

b
...

c
...

d
...

A nurse who is caring for a group of clients delegates collection of vital signs to an assistive personnel
(AP)
...
Review vital sign trends at the end of the shift
...
Recheck vital signs that are outside the expected reference range
...
Ask the AP to write a summary of the delegated tasks during the shift
...
Compare the vital signs the AP obtained with those taken by another AP on a previous shift
...
Which of the following tasks can be delegated to an assistive personnel?
a
...
Monitoring a client who has a fluid restriction
c
...
Reviewing dietary instructions for a client who has kidney stones
A nurse is triaging a group of clients following a disaster
...


11
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13
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15
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17
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A client who has a neck injury and is unable to breathe spontaneously
b
...
A client who has major burns over 75% of her body surface area
d
...
Which of the
following statements by a staff nurse indicates that the teaching was effective?
a
...
”
b
...
”
c
...
”
d
...
”
A nurse is caring for four clients
...
A middle adult client who leaves the facility against medical advice
b
...
A young adult client who is participating in a medical research study
d
...
The nurse should explain that which of the following is an objective of telehealth?
a
...
Developing client treatment protocols
c
...
Establishing communication between providers (Community Health pg
...
The client
expresses concern about the cost of blood-glucose monitoring supplies
...
Refer the client to the social services department
...
Provide the client with a week’s worth of supplies from the hospital (still needs help paying after)
c
...
Recommend the client reuse the testing lancets (breaks the safety & infection protocol)
A charge nurse is receiving change-of-shift report
...
A nurse on the previous shift wrote an incident report about a medication error
...
Two staff members have called to say they will be absent
...
Transport assistance is unavailable to take a client to occupational therapy
...
The emergency department nurse is waiting to give report on a new admission
...
Which of
the following actions should the nurse preceptor take first to demonstrate appropriate time management?
a
...

b
...

c
...
Document assessment data
...
Which of the following
statements by a staff nurse indicates understanding?
a
...
”
b
...
”
c
...
”
d
...
”
A nurse is caring for a client who has a tumor
...
The client refuses, but
the client’s partner wants the surgery performed
...
Whether the client understands the risk of refusing the procedure
b
...
Whether the partner is the client’s durable power of attorney for health care
d
...
A charge nurse is planning the care of four newborns
...
Which of the following tasks should the nurse assign to a licensed practical
nurse?
a
...
(RN assessment)
b
...

c
...
(RN assessment)
d
...
(CNA)
19
...
Which of the following strategies should the nurse manager implement
first?
a
...

b
...

c
...

d
...

20
...
The nurse should explain that preventing
client injury by removing a fall hazard demonstrates which of the following ethical principles?
a
...
Autonomy
c
...
Veracity
21
...
Which of the following clients should the nurse plan to assess first?
a
...
9 kg (2 lb) in the past 24 hr (improvement)
b
...
A client who has a nasogastric tube and has crackles in the lungs (ABC--airway)
d
...
2 microunits/mL
22
...
Which of
the following clients should the nurse evacuate first?
a
...
A client who is 1 day postoperative following thoracic surgery and has a chest tube (possible
physical instability)
c
...
A client who is receiving IV chemotherapy and is ambulatory
23
...
Which of the following actions should the
nurse take first?
a
...

b
...

c
...

d
...

24
...
Just before the procedure, the client asks the nurse
about the risks of the procedure
...
Explain the risks of the procedure to the client
...
Convey the client’s request to the nurse who witnessed the consent
...
Check to see if the medial record indicates the provider explained the procedure to the client
...
Notify the provider about the client’s concerns
...
A nurse is prioritizing care after receiving change-of-shift report on four clients
...
A client who reports a headache with sensitivity to light
b
...
A client who reports indigestion and pain in her jaw
d
...
A charge nurse notices that two staff nurses are not taking meal breaks during their shifts
...
Discuss time management strategies with the nurses
...
Determine the reasons the nurses are not taking scheduled breaks
...


28
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30
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32
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34
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Provide coverage for the nurses’ breaks
...
Review facility policies for taking scheduled breaks
...
Which of the following assessments should the nurse
make before delegating care?
a
...
Is the client’s family present so the AP can show them how to turn the client? (this is not
necessary)
c
...
Does the AP have the time to change the client’s central IV line dressing after turning her? (AP
cannot change dressings)
A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the
SBAR communication tool
...
A prescribed consultation -under situation
b
...
The client’s name -under situation
d
...
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
...
”
b
...
”
c
...
”
d
...
”
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
...
Which of the following actions should the nurse?
a
...

b
...

c
...

d
...

A nurse on a medical-surgical unit is caring for four clients
...
A client who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds
b
...
A client who had a cholecystectomy 6 hr ago and is requesting pain medication
d
...
Which of the following actions should the
charge nurse take?
a
...

b
...

c
...

d
...

A nurse is assessing a client’s comprehension of a pulmonary function test prior to the procedure
...
“I will be given contrast dye during this test
...
“I might have to wear a nose clip during this test
...
“I might have a tube inserted into my airway during the test
...
“I will run on a treadmill during this test
...
Which of the following clients should the
nurse recommend to be examined first?
a
...
79 in) head laceration oozing dark red blood
b
...


36
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38
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40
...


42
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An older adult client who has dyspnea and a respiratory rate of 26/min
d
...
The nurse explains the
need to discard the newspapers for safety reasons
...
Which of the following conflict resolution strategies has the nurse used?
a
...
Smoothing
c
...
Compromising
A nurse is planning to delegate client care assignments
...
Advising a client on self-administration of acetaminophen
b
...
Teaching a client to perform a finger-stick for testing blood glucose levels
d
...
Which of the
following information should the nurse include (SATA)
a
...
Contact information for the physical therapist
c
...
Insurance information
e
...
When the client’s partner asks how this service can help, which of the following
responses by the nurse is appropriate?
a
...
”
b
...
”
c
...
”
d
...
”
A nurse is teaching a client how to use a finger-stick glucometer at home
...
Warm the hands prior to piercing the skin
...
Cap the lancet prior to putting it in the trash
...
Elevate the arm for 1 min before taking the blood sample
...

d
...

A nurse is assessing a client who had a recent stroke
...
Receptive aphasia→ unable to understand language in its written or spoken form
b
...
Memory loss
d
...

A nurse is participating in the development of a disaster management plan for a hospital
...
A network for communication between staff members and families
b
...
A sufficient supply of personal protective equipment
d
...
Which of the following diseases
should the nurse report to the state health department?
a
...
Pertussis
c
...
Group B streptococcal disease

43
...
Which of the following solutions should the nurse recommend to clean the
equipment?
a
...
Triclosan
c
...
Isopropyl alcohol
44
...
The nurse suspects elder abuse
...
Treat and discharge the client
...
Ask the client’s son to go to the waiting area
...
File an incident report
...
Ask the client about his injuries with the son present
45
...
Which of
the following statements by the client indicates an understanding of the teaching?
a
...
”
b
...
”
c
...
”
d
...
”
46
...
The nurse should recognize that which of
the following can be delegated to an assistive personnel?
a
...
Recording the client’s vital signs
c
...
Determining the client’s pain level
47
...
Which of the
following is an appropriate task for the AP?
a
...
– Assess
b
...
- Teaching
c
...
- Teaching
d
...
A nurse is orienting a newly licensed nurse about the use of restraints
...
“A provider can write a prescription for restraints ‘as needed’
...
“I need to tie the restraint to the part of the bed frame that moves
...
“I should tie the restraints using a square knot
...
“I will remove a client’s restraints every 4 hours
...
An infection control nurse is planning an education program for a group of newly licensed nurses
...
Mumps
b
...
Varicella
d
...
A nurse is caring for a client who has cancer
...
Which of the following statements by the nurse is appropriate?
a
...
”
b
...
”
c
...
”
d
...
”
51
...
Which of the following tasks should the
nurse plan to delegate to an assistive personnel?
a
...

b
...

c
...

d
...


52
...
Which of the
following actions should the charge nurse take first?
a
...
(4)
b
...
(2)
c
...
(1)
d
...
(3)
53
...
The nurse manager should identify that
which of the following torts has occurred? P
...
Libel : talking bad about someone via writing it in notes
b
...
Slander : Defamation with the spoken word
d
...
A nurse is preparing a client for an elective mastectomy
...

Which of the following is an appropriate procedure for taking care of this client’s ring?
a
...

b
...

c
...

d
...

55
...
Which of the following actions should the nurse
take first?
a
...

b
...

c
...
Instruct a client who has an episiotomy about a sitz bath
...
A hospice nurse is caring for a client who has a terminal illness and reports severe pain
...

Which of the following actions should the nurse take?
a
...

b
...

c
...

d
...

57
...
9% sodium chloride enema to an adult client
...
Administers the solution at room temperature
b
...
Position the client on her left side with knees flexed
d
...
1 in) into the rectum
58
...
The nurse should explain that
advance directives include which of the following? P
...
Instructions regarding treatments the client desires or does not desire – (livings wills and
durable power of attorney make up AD)
...
Information regarding the disposition of the client’s body upon death
c
...
A form with directions for contacting next of kin
59
...
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
...
A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38C (101F)
d
...
A staff development nurse is giving an in-service presentation about advocacy in nursing
...
“In the role of client advocate, I should take responsibility for coordinating each client’s care
...

c
...


62
...


64
...


66
...


68
...
”
“My role as a client advocate is to empower the clients to make informed healthcare
decisions
...
“As a client advocate, I will adhere to the provider’s prescribed treatments
...
Which of the following actions should the nurse take first?
a
...

b
...

c
...

d
...

A nurse at the local health department is caring for four clients who have communicable diseases
...
Chlamydia trachomatis
b
...
Impetigo contagiosa
d
...
Which of the following actions should the charge
nurse take?
a
...

b
...

c
...

d
...

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
...
Accept the assignment with help from assistive personnel on the unit
...
Request that the charge nurse modify the assignment
...
Document the concern in the nurse’s notes
...
Notify the risk manager
...

Which of the following information should the nurse include in the teaching as an example of advocacy?
a
...
Suggesting a client’s partner attend a support group for emotional support
c
...
Completing an incident report following a medication error
A charge nurse in the emergency department is supervising a nurse who is floating from the medicalsurgical unit
...
Administer IV nitroglycerin to a client who is experiencing chest pain
...
Perform a urinary catheterization for a client who has experienced a cerebrovascular
accident
...
Set up a trauma room for an incoming client who was in a motor-vehicle crash
...
Complete a SAD PERSONS assessment scale for a client who has attempted suicide
...
Which of the following findings should the nurse identify as increasing the client’s risk for falls?
(SATA)
a
...
A wheeled office chair at the client’s computer desk
c
...
A two-wheeled walker used to assist the client with ambulation
e
...
Turning off room lights at night
b
...
Restricting space to reduce pacing
d
...
A nurse in the emergency department is preparing to care for a client who arrived via ambulance
...
Which of the following actions should the nurse take?
a
...
Notify risk management before initiating treatment
c
...
Contact the client’s next of kin to obtain consent for treatment
70
...
Which of the following actions should the nurse take first?
a
...

b
...
Observe the client’s condition
...
Complete an incident report
...


2
...


4
...


6
...


A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound
care procedure
...

a
...
Deep red color on the center of the clients wound
c
...
Increase in serosanguineous exudate from the clients wound
A nurse received change of shift report at 0700 for four clients
...
Obtain a breakfast tray for a client who received a morning dose of insulin aspart
b
...
Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
d
...
(To
prevent bacterial contamination, fill the bag with only enough formula to last over a 4-8 hour
period, and change the feeding bag every 24 hours)
A nurse is orienting a newly licensed nurse on the neurological unit
...
A client who has multiple sclerosis and ataxia
b
...
A client who has guillain-barre syndrome and a tracheostomy
d
...
Which of the following statements by
the client indicates an understanding of the teaching?
a
...
“I will wait until I have a serious health problems to sign my advance directives”
c
...
“My durable power of attorney for health care is part of my advance directives”
A nurse is chairing a committee about preventing infant abduction in a new birth care center
...
Identify the industry standards for infant safety
b
...
Choose an infant safety system
d
...

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
c
...
Occupational therapist
A home health nurse is assessing the home environment during an initial visit to a client who has a history
of falls
...


9
...


11
...


13
...


15
...
Which of the
following clients should the nurse assign to a LPN
a
...
A middle adult client who has a below the knee amputation and requires a dressing change
c
...
An adolescent who requires teaching regarding insulin administration
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
...
Remind nurses to obtain this information during the admission process
b
...
Meet with nursing staff to review the policy regarding advance directive
d
...
Which of the following should the nurse see first?
a
...

b
...
A client who has diabetes mellitus and is diaphoretic
d
...
Which of the following clients should the nurse
care for first?
a
...
A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea
c
...
A client who has a new colostomy and requires discharge teaching
A nurse manager discovers there is a conflict between nurses working the day shift and nurses working on
the night shift
...
Acknowledge the conflict and encourage the nurses to focus on working as a team
b
...
Encourage the nurses to resolve the conflict autonomously
d
...
Which of the following actions should the nurse take first?
a
...
Irrigate the exposed area with water
c
...
Report the incident to OSHA
A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client
...
Complete an incident report
b
...
Inform the nurse manager
d
...
Which of the following findings should the nurse report
to the provider immediately?
a
...
Generalized rash over trunk
c
...
Report of photophobia

16
...
In accordance with the care
pathway, antibiotic therapy is prescribed
...
Antibiotic therapy was initiated 2 hr after implementation of the care pathway
...
A blood culture was obtained after antibiotic therapy had been initiated
c
...
The route of antibiotic therapy on the care pathway was changed from IV to PO
17
...
Which of the following
clients should the nurse manager assign to a float nurse from the medical-surgical unit?
a
...
A client who gave birth to her first child and requires instruction on breastfeeding techniques
c
...
A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion
18
...
Which of the following members of the
interprofessional team should the nurse consult?
a
...
Clinical pharmacist
c
...
Infection control nurse
19
...
The provider has recommended a total abdominal
hysterectomy, but the client tells the nurse that the surgery is not an option
...
Discuss with the client her concerns regarding the procedure
b
...
Inform the client of the consequences of uterine prolapse and the need for intervention
d
...
A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle
crash
...
Which of the following actions should the nurse take?
a
...
Obtain telephone consent from the facility administrator before the surgery
...
Ask the anesthesiologist to sign the consent
...
Transport the client to the operating room without verifying informed consent
...
A nurse is planning to delegate client care assignment
...
Performing postmortem care prior to transferring the client to the morgue
b
...
Teaching a client to perform a finger-stick for testing blood glucose levels
d
...
A nurse is working on a quality improvement team that is assessing an increase in client fall at the facility
...
Notify staff of the increased fall rate
b
...
Implement a fall prevention plan
d
...
A nurse is completing performance evaluation for an assistive personnel (AP)
...
The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile
...
The AP closes the door of a client who is on airborne precautions
...
The AP Removes cut flowers from the room of a client who is in protective environment
...
The AP wears a mask when a caring for a client who has varicella
...
A charge nurse notices that the staff nurse are having difficulty using new IV infusion pumps for
medication administration
...
Assess the staff nurse’s knowledge deficit
...


26
...


28
...


30
...


32
...
Pair an inexperienced nurse with an experienced nurse
...
Demonstrate use of the pump during medication administration
...
Plan an in-service education program on the unit
...
Which of the following
tasks should the nurse assign to the AP?
a
...
Check a client pain level 30min after receiving acetaminophen
c
...
Instruct a client to splint an abdominal incisions
A nurse is assisting with triage during a mass casualty event
...
Which
of the following actions should the nurse take?
a
...
Provide treatment for life-threatening injuries
c
...
Allow the client to die without further intervention
A home health nurse is performing a safety assessment of a client’s home
...
The client has used tracks to secure the carpet on the stairs
b
...
The client’s bedside lamp is plugged in using an extension cord with two prongs
d
...
Which of the following actions by the newly licensed nurse indicate an understanding of proper
infection control procedures?
a
...
Removes fresh flowers from the client’s room
...
Washes her hands with an alcohol-based hand rub after caring for the client
...
Wears gown when caring for client
A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube
...
Pipe cleaners
b
...
Cotton balls
d
...
Obturator
A nurse is caring for four clients who are scheduled to undergo surgery
...
An adult client who has alcohol intoxication- NOT FOCUSED
b
...
An older adult client who has questions about the procedure= having questions means you dont
understand,
d
...
- cant consent if you are not FOCUSED
A nurse is discussing the safekeeping of valuables with a client who is scheduled for surgery
...
“I can wear my ankle bracelet since i am just having a local anesthetic:
b
...
“I should remove my dentures before the procedure”
d
...
The nurse requests a
consultation with the wound care specialist
...
Request the consultation after several wound care treatments are tried
b
...


33
...


35
...


37
...


39
...


41
...
Provide the consultant with subjective opinions and beliefs about the client’s wound care
A nurse is observing an AP administer 0
...
For which of the
following actions by the AP should the nurse intervene?
a
...
Administers the solution at room temp
c
...
Inserts the tubing 8cm (3
...
Which of the following statements
by the newly licensed nurse indicates an understanding of the teaching?
a
...
”
b
...
”
c
...
“I should discard personal health information documents in the trash before leaving the unit”
A nurse is participating on a committee that is considering the creation of a policy that will allow the
nurses to remove chest tubes
...
ANA Standards of Practice
b
...
State Nurse Practice Act
d
...
The LPN does not return with the medication
...
Veracity
b
...
Fidelity
d
...
Which of the following actions should the nurse take?
a
...
Establish work initiatives to promote a positive environment
c
...
Determine how current practice will affect future performance within the facility
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
...
Place a faulty equipment tag on the pump
b
...
Auscultate the client’s lungs
d
...

Which of the following nursing statements is an appropriate nursing response?
a
...
“Why did you make the decision to have this procedure?”
c
...
“You shouldn’t be worried because the procedure is very safe”
A facility infection control nurse is reviewing the reports of a group of clients
...
Lyme disease
b
...
Health care-acquired pneumonia
d
...
Which of the following
information should the nurse include in the change-of-shift report?

42
...


44
...


46
...


48
...


50
...
The steps to follow when providing wound care
b
...
The belief that the client has a difficult relationship with his son
d
...
Which of the following
actions should the nurse take first
a
...
Read back the prescription to the provider
c
...
Ensure that the provider signs the prescription
A charge nurse witnessed an assistive personnel failing to follow facility protocol when discarding
contaminated linens
...
Discuss the issue with the AP
b
...
Reinforce facility protocols at the next staff meeting
d
...
Which of the
following actions should the nurse include in the plan?
a
...
Remove the clock and calendar from the client’s room
c
...
Provide distractions for the client during the day
A nurse is caring for a client who has a new diagnosis of chlamydia
...
Initiate contact precautions (standard)
b
...
Apply an antiviral cream to lesions
d
...
The nurse should
include which of the following as the first step in evidence-based practice?
a
...
Develop a clinical question
c
...
Collect evidence from a variety of sources
A nurse assumes the leading role on the hazardous materials team immediately following a chemical mass
casualty incident in the community
...
Place shower caps over the client's’ hair
b
...
Scrub the client’s skin with betadine solution
d
...
The nurse manager should identify that
which of the following torts has occurred?
a
...
Negligence
c
...
Slander
A nurse is preparing to complete morning assignments on several assigned clients
...
A client who had a bladder scan that indicated 250 mL of urine in the bladder
b
...
A client who has diabetes and an early morning blood glucose of 220 mg/dL
d
...
Which of the
following responses should the charge nurse make?

51
...


53
...


55
...


57
...


a
...
“Do you understand the HIPAA regulations?”
c
...
“I will notify the client’s provider about this breach of confidentiality
A nurse preceptor is observing a newly hired nurse perform a sterile dressing change
...
Places sterile gauze 1
...
5 in) away from the edge of a sterile drape
b
...
Sets up the sterile field 30 min prior to performing the dressing change
d
...

A nurse working in a long-term care facility is assessing an older adult client who has been receiving
antibiotics for 10 days
...
Which of the following actions should the
nurse take?
a
...
Perform hand hygiene with alcohol based hand sanitizer
...
Clean the equipment in the client’s room with bleach
...
Initiate droplet precautions for the client
...
The newly licensed nurse is having trouble
focusing and has difficulty completing care for his assigned clients
...
Advise him to complete the less time consuming tasks first
b
...
Offer to provide care for his clients while he take a break
d
...
The nurse initiates a referral for a social
worker
...
The client needs to have someone bring O2 tanks and equipment to her home
b
...
The client needs to arrange financial resources to purchase equipment
d
...
Which of
the following assessment findings supports the need for this referral?
a
...

b
...

c
...
The client has difficulty ambulating with a walker
A nurse is caring for a client who has anorexia nervosa
...
Nutritional therapists
b
...
Mental Health counselor
d
...
Physical therapist
A nurse is prioritizing care after a receiving change-of-shift report on four clients
...
A client who reports a headache with sensitivity to light
...
A client who reports feeling lightheaded when he stands up from a lying position
c
...
A client who reports an urge to void but has not urinated during the prior shift
A nurse on an acute mental health unit is assessing four clients
...
A client who has depressive disorder and has poor personal hygiene
b
...
A client who has bipolar disorder and displays constant pacing – (Can lead to physical
exhaustion and death)

d
...
A nurse is planning care for a group of clients
...
Obtain a breakfast tray for a client whose total parenteral nutrition was discontinued 4 hrs ago
...
Auscultate the bowel sounds of a client who has not had bowel movement after taking a laxative
12hr ago
...
Provide instruction to the caregiver of a client who has dementia and new diagnosis of diabetes
mellitus
...
Check a client who has a leg cast and reports a new onset of pain
...
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
...
“You must choose a member of your family to serve as a your health care proxy
...
“A health care proxy can make decisions for you when you are unable to do so
...
“You should appoint a health care proxy before undergoing an invasive procedure
...
“It is necessary for an attorney to approve your health care proxy
...
A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that
day
...
” Which of the
following actions should the nurse take first?
a
...

b
...

c
...

d
...

62
...
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
c
...
A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38C (101F)
63
...
Which
of the following actions should the nurse take?
a
...

b
...

c
...

d
...

64
...
Which of the
following actions should the nurse take first? [repeat]
a
...
Review facility policies for taking scheduled breaks
...
Provide coverage for the nurses’ breaks
d
...

65
...
The nurse distracts the
client and quickly administers the injection
...
False imprisonment
b
...
Assault
d
...
A nurse is speaking with a visitor who asks a questions about the status of a relative who is a fadovclient
on the unit
...
“I’m not taking care of your relative today, so I don’t have the latest information”
b
...
”
c
...
”
d
...
”

67
...
The client’s
partner asks the nurse how that would help
...
Allow her to take time off from attending to her partner
b
...
Send a clinician to assess the safety of leaving her partner alone
d
...
A charge nurse observes a client fall during ambulation and notes that his gait belt was not in place
...
Which of the following ethical
principles should guide the nurse’s subsequent actions?
a
...
Veracity - commitment to tell the truth
c
...
Beneficence - promote good for others
69
...
Which of
the following actions is the nurse’s responsibility in the informed consent process?
a
...
Review the risks and benefit of the procedure with the client
c
...
Assess the client’s understanding after the provider has talked with her
70
...

Which of the following instructions should the nurse include in the teaching?
a
...

b
...
Attach the restraints to the fixed portion of the frame of the client’s bed
d
...
A nurse is preparing an educational program for staff members 2 a new intravenous pump
...
(Move the steps into the box on the right, placing
them in order of performance)
...
A nurse suggest respite care for the partner of a client who has mild impairment
...
The nurse should explain that respite care would do which of the following?
 Allow her to take time off attending to her partner
3
...
Which of the following actions should the case manager take
first?
 Offer to have a brief talk with the caregiver
4
...
In which of the following actions is the
nurse acting as a client advocate?
 Requesting a referral for the client to attend reminiscent therapy sessions
5
...
Which of the following statements
by a staff nurse indicate understanding of the teaching (SATA)
...
”
 “I can delegate the removal of an IV catheter to an LPN on the unit
...
”
6
...
Which of the following statements by the client indicates an
understanding of advance directives?
 “I know I have the right to determine if I remain on a breathing machine
...
A nurse is caring for a client who has a pressure ulcer on the coccyx
...
A nurse on a medical-surgical unit delegating client care
...
A nurse is providing teaching about infection control measures to a client who has an indwelling urinary catheter
...
A nurse manager is preparing an in-service for a group of staff nurses about organ donation
...
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite
...
” [repeat]
12
...
Which
of the following actions by the newly licensed nurse demonstrates an understanding of the process?
 Clamps the air vent tubing
13
...
To which of the following clients should the
nurse assign priority?
 A client who has soot markings around each naris following a house fire
14
...
Which of the following clients should the
nurse assess first?
 An older adult client who has bacterial pneumonia and a new onset of restlessness
15
...
Which of the following clients is appropriate
to assign to a licensed practical nurse?
 A client who has emphysema and has oxygen saturation of 92%
16
...
The client does not speak English and is
accompanied by her adult daughter
...
A nurse is caring for a client who has an MI
...
Which of the following responses should the nurse make?
 “Your father will have to give permission for you to review the record
...
A nurse is teaching a client who requires protective isolation due to immune system compromise
...
”
“Wear gloves and a gown whenever you need to leave your room
...
”
19
...
The client’s
parents are en route to the facility but have not spoken with the surgeon
...
A nurse is preparing a client for surgery
...
Which of the following responses by the nurse is appropriate?
 “I understand, and it’s not too late to change your mind
...
A nurse is completing discharge teaching with a client who is being treated with tuberculosis (TB)
...
A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube
...
A nurse is completing discharge teaching about dietary supplements for nitrogen loss with a client who has
cancer
...
A case manager is preparing a client who has a spinal cord injury for discharge from the rehabilitation setting to
home
...

A nurse is chairing a committee about preventing infant abduction in a new birth care center
...

o Evaluate the selected infant safety system
...

o Identify the industry standards for infant safety
...

A nurse at a local health department is caring for four clients who have communicable diseases
...

A nurse at a clinic is teaching a newly licensed nurse about sexually transmitted infections
...

o Candidiasis
o Gonorrhea
o Trichomoniasis
o Human papillomavirus
4
...
Which of the
following actions should the charge nurse take first?
o Review with the nurse principles of medication administration
...

o Identify education opportunities for the nurse regarding safe medication administration
...

5
...
The oldest adult child has durable power of attorney for health care for
the client
...
Which of the following people has the legal authority to
make the health care decision?
o The provider
o The oldest adult child
o The partner
o The client
6
...
After
gathering data, identify the sequence the committee should follow when using the stages of change
...

4
7
...
Which of the following information
should the nurse include in the report?
o “ The client’s partner came to visit him 2 hours ago and smelled of alcohol
...
”
o “ The client will need vital signs checked every 4 hours
...
”
8
...
The
parent states she is unable to afford the nebulizer prescribed for the child
...

A nurse is preparing a shift assignment for an assistive personnel on the unit
...
A nurse is teaching a class of newly licensed nurses about evidence- based practice
...

o Collect evidence from a variety of sources
o Develop a clinical question
o Apply research to client care practice
o Critically assess the evidence

11
...
The nurse should tag and report which of the following
safety hazards?
o The electrical cord is taped to the floor
o The IV pump is plugged into an outlet close to the bed
o The IV pump has a free-flow protective device
o The electric plug has two short prongs – (Must be 3 prongs)
12
...
Which
of the following actions should the nurse take to evaluate the delegated task?
o Recheck vital signs that are outside the expected reference range
o Review the vital sign trends at the end of the shift
...

o Compare the vital signs the AP obtained with those taken by another AP on a previous shift
...
A nurse is caring for a client who has signed consent for the removal of the tumor in the left frontal lobe of the
brain
...
” Which of the following actions should the nurse
take?
o Continue with the surgery because the client already gave informed consent
...
A nurse is preparing to witness a client’s signature on an informed consent for a surgical procedure
...
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
...

o Contact the house supervisor to mediate the conflict

o Escort the nurses to the nurses lounge to continue the discussion
o Recommend that both nurses are terminated
16
...
9% sodium chloride enema to an adult client
...
1 in) into the rectum
o Positions the client on her left side with knees flexed
o Points tubing in the direction of the umbilicus during insertion
o Administers the solution at room temperature
Rationale: Prepare and warm the enema solution
...
Slowly insert the rectal tube 7
...

17
...
Which of the following clients should the
nurse assess first?
o A client who reports feeling lightheaded when he stands up from a lying position
o A client who reports an urge to void but has not urinated during the shift prior
o A client who reports indigestion and pain in her jaw
o A client who reports a headache with sensitivity to light
18
...

Which of the following instructions should the charge nurse give to the unit nurses?
o Ask ambulatory clients to help move clients in wheelchairs to safety
o Continue therapy for clients who are receiving oxygen
o Close the doors of the unit before moving clients to a safe place
o Maintain mechanical ventilation for clients who are on life support
...
A nurse is providing teaching to an older adult client regarding home safety
...
A nurse is using the SBAR communication tool while giving report on a client
...
A nurse is comparing the rate of medication errors on the medical unit to the rate from a medical unit in a
magnet hospital
...
A nurse is planning a discharge for a client who has a new diagnosis of COPD and lives alone
...
A nurse is caring for a group of clients
...
A nurse manager is reviewing documentation on several clients and notes a progress report that falsely identifies
a client as an HIV-positive due to multiple sexual partners
...
A nurse initiates a referral to an occupational therapist for a client who has rheumatoid arthritis
...
A home health nurse finds piles of newspaper in the hallway of a client’s home
...
The client agrees to move the newspapers into the living room
...
A nurse reports to a charge nurse that a client’s visitor slipped and fell
...
Which of the following instructions should the charge nurse give the nurse?
o “ Have the visitor sign a waiver”
o “ Document the incident report in the client’s medical record”
o “Offer the visitor an analgesic”
o “ Record the event on an occurrence report”
28
...
Which of the following
information should the nurse plan to include?
o A code of ethics is a step-by-step approach to decision making
o A code of ethics is legally binding
o A code of ethics outlines the nurses scope of practice
o A code of ethics is a set of principles for nursing practice
29
...
Which of the
following infections should the nurse include when discussing illnesses requiring droplet precautions?
o Rotavirus
o Rubeola
o Varicella
o Mumps
30
...
Which
of the following actions should the nurse take?
o Gather information regarding the situation
o Acknowledge the conflict and encourage the nurses to focus on working as a team
o Encourage the nurses to resolve the conflict autonomously
o Meet with the a committee of nurses from each shift to discuss issues related to the conflict
31
...
After donning a sterile gown
and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?
o The nurse puts on a face mask
o The nurse applies goggles
o The nurse holds her hands above her waist
o The nurse turns her back to the sterile field
32
...
Which of the following clients should the nurse
recommend to be examined first?
o An adolescent who has an injured ankle and reports a pain level of 8 on a scale of 0-10
o A toddler who has a 2cm (0
...
A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS)
...
A nurse in a long-term care facility is planning a fall prevention program for the residents
...
A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility
...
A nurse is caring for four clients who are scheduled to undergo surgery
...
A nurse is completing a performance evaluation for an assistive personnel
...
A nurse is caring for four clients
...
A nurse is working with a licensed practical nurse (LPN) to care for a group of clients
...
A nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of
MRSA
...
A charge nurse provides an annual in-service for the nursing staff regarding ethical practice
...

o A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate
of 8/min
...
A nurse is conducting an in service about the nursing code of ethics with a group of newly licensed nurses
...
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
...
A nurse is documenting and completing an incident report after a client falls out of bed
...
A nurse is planning discharge teaching for a client who has a newly placed tracheostomy tube
...
A nurse is providing discharge teaching to a client following total knee arthroplasty
...
A charge nurse overhears a staff nurse discussing a client’s diagnosis in the cafeteria
...
A nurse is caring for a client who reports taking a new herbal supplement after reading about it on the Internet
...
Net) websites
o Ensure the website is sponsored by a pharmaceutical company
o Consider the Internet information reliable if it is written by a doctor
49
...
The nurse should explain that preventing
client injury by removing a fall hazard demonstrates which of the following ethical principles?
o Veracity – nurse’s duty to tell the truth
o Nonmaleficence – nurse’s obligation to avoid causing harm to the client
o Utility
o Autonomy – the ability of the client to make personal decisions
50
...
The client expresses concern that someone might steal her purse during
the procedure
...
A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to
a client
...
A home health nurse is assessing the home environment during an initial visit to a client who has a history of
falls
...
A nurse on a medical- surgical unit is caring for a client who asks about advance directives and states the he
wants to appoint a health care proxy
...
A nurse is preparing to transfer a client to the radiology department using the wheelchair
...

o Test the locks on both wheels of the chair prior to transfer
...
A nurse is providing an in-service about client rights for a group of nurses
...
”
o “A nurse is responsible for informing clients about treatment options”
56
...
Which of the following actions should the
charge nurse take?
o Assign clients who are not prescribed narcotics to the staff nurse
o Counsel the staff nurse about substance abuse use
o Collect data about the staff nurse to support further action Always assess first
o Report the staff nurse to the facility ethics committee
57
...
Which of the following actions should the nurse plan to take?
o Limit interpreter services to daytime hours
o Repeat the same words to the interpreter if the client does not understand
o Assign a bilingual staff member to be the interpreter when caring for the client
o Pause in the middle of the sentence when using an interpreter
58
...
Which of the following tasks should the nurse plan to
delegate to an assistive personnel? REPEAT QUESTION
o Explain to the client about a 24hr urine specimen collection RN
o Determine the client’s muscle strength prior to ambulation RN
o Decide how often to measure vital signs RN
o Remind the client to change positions slowly within AP scope
59
...
The nurse should
arrange a referral to which of the following members of the interprofessional team regarding the client’s condition?
o Speech pathologist – Evaluates and makes recommendations regarding the impact of disorders or
injuries on speech, language, and swallowing
o Occupational therapist
o Physical therapist
o Social worker
60
...
Which of the following clients should the nurse identify as priority?
o A client who has a red tag
o A client who has a yellow tag (delayed – serious but not life threatening)
o A client who has a green tag (minor, walking wounded)

o A client who has a black tag
61
...
The nurse suspects elder abuse
...
A charge nurse is reviewing the actions by a nurse following a client fall
...
A nurse on a medical-surgical unit is making staff assignments
...
A nurse is caring for a client who is scheduled for placement of central venous access device
...
A nurse is orienting a newly licensed nurse about the use of restraints
...
A nurse is receiving change of shift report for four clients
...
A charge nurse is receiving change of shift report
...
A nurse is providing information to a client about advance directives
...
A nurse is reviewing medication administration record of a client and notices that an additional dose of
medication has been administered
...
A nurse is assessing a client who has meningitis
...
A nurse is evaluating a newly licensed nurse who is administering a vitamin K injection to a newborn
...
Applies gentle pressure at the site after injection
b
...
Selects the dorsogluteal site to administer the injection
d
...
Cleans the injection site with alcohol
Rationale: https://www
...
com/ati_next_gen/skillsmodules/content/medication-administration3/equipment/intramuscular-injections
...
A nurse manager is reviewing guidelines for informed consent with the nursing staff
...
“Guardian consent is required for an emancipated minor
...
“Consent can be given by a durable power of attorney
...
“The nurse can answer any questions the client has about the procedure
...
“A family member can interpret to obtain informed consent from a client who is deaf
...
A nurse is teaching a client how to use a finger-stick glucometer at home
...

Obtain the blood sample from the finger pads
...

Elevate the arm for 1 min before taking the blood sample
...

Cap the lancet prior to putting it in the trash
...

Warm the hands prior to piercing the skin
4
...
Which of the following findings should the nurse report to the provider?
a
...

Oxygen saturation 89% on room air
c
...
Bilateral crackles on auscultation of lungs
5
...
Which of
the following nursing statements is an appropriate nursing response?
a
...
”
b
...
”
c
...

“It’s not too late to cancel the surgery if you want to
...
A nurse is caring for a client who reports acute pain but refuses IM medication
...
This illustrates which of the following?
a
...

False imprisonment
c
...

Assault
7
...
Which
of the following actions should the nurse take first?
a
...

b
...

c
...

d
...

8
...
After developing an
initial plan, in which order should the nurse take the following steps?

 Determine goals
 Implement recommended strategies
 Revise the plan
...
A nurse is orienting to an emergency department
...
Which of the following is the best resource for this nurse?
a
...

The provider suturing the client’s injury
c
...

The information on the suture package
10
...
Drug use is suspected in
the crash, and a voided urine specimen is ordered
...
Which of
the following is the appropriate action by the nurse?
a
...

b
...

c
...

d
...

11
...
Which of the following is the priority action for the
nurse to take?
a
...

b
...

c
...

d
...

12
...
Which of the
following actions should the nurse preceptor take first to demonstrate appropriate time management?
a
...

b
...

c
...

d
...

13
...
A charge nurse recognizes a need for
further education when which of the following behaviors is observed?
a
...

b
...

c
...

d
...

14
...
The partner has
spoken with the provider and wishes to discontinue the client’s feeding tube
...
His partner has no right to make decisions regarding the client’s care
...

“We’ll need to have the nursing supervisor review the client’s advance directives
...

“You should consider speaking with the facility’s ethics committee before making your decision
...

“You have the right to make that decision, even if the partner is the client’s health care proxy
...

“The client has designated his partner as health care proxy in his advance directives
...
A parish nurse is making a referral to a community meal delivery program for a member of the congregation
...

Health educator
b
...

Pastoral care provider
d
...
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
...

Laboratory results within the expected reference range
b
...

List of regularly prescribed medications
d
...
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
...

“Carry your baby snugly in your arms whenever you leave your room
...

“Make sure to leave your baby in the bassinet by your bed when you use the bathroom
...

“Keep your baby next to you in your bed if you think you might fall asleep
...

“Check the photo identification badge of staff members who care for you and your baby
...
A nurse is assigned the following four clients for the current shift
...

A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot
b
...

A client who has aspiration pneumonia and a respiratory rate 28/min ABC
d
...
A nurse should recognize that an incident report is required when
a
...

b
...

c
...

d
...

20
...
Which of the following tasks is appropriate to
delegate to a licensed practical nurse?
a
...

Providing the first oral feeding to a client following a stroke
c
...

Changing the dressing on a postoperative wound
21
...

The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter
...

“Are you removing the client’s restraints every 4 hours?”
b
...

“Did you tie the restraints using a double knot?”
d
...
A nurse observes a paper bag at the bedside of a client
...

Stridor
b
...

Hyperventilation
d
...
Which of the following observations requires a charge nurse to intervene and demonstrate safe handling
techniques?
a
...

b
...

c
...

d
...

24
...

Which of the following actions indicates the nurse is maintain sterile technique? (SATA)
a
...

Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field
c
...
25-cm (0
...

Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
e
...
A nurse working on a medical-surgical unit is receiving shift report regarding four clients
...

A 75-year-old man who has pneumonia and has a O2 saturation of 92%
b
...
2° C (100
...

A 45-year-old man who has new onset of confusion 24 hr after a total hip arthroplasty
d
...
An RN is planning client assignments for a licensed practical nurse (LPN) and three assistive personnel
...

Recording of daily intake and output
b
...

A complete bed bath
d
...
A client has a new permanent pacemaker inserted
...

Swimming could cause the unit to have an electrical short
...

The client should avoid using remote control devices to prevent dysrhythmias
...

Regular programming evaluations can be conducted by telephone
...

The client should avoid using a microwave oven to heat food
...
According to HIPAA regulations, which of the following is a violation of client confidentiality?
a
...

Informing housekeeping staff that the client is in the dialysis unit
c
...

Telephoning the pharmacy with a prescription for the spouse to pick up
29
...
The nurse
should assess the client’s need for which of the following to manage the tracheostomy at home? (SATA)
a
...

Cotton balls
c
...

Oxygen tank
e
...
A nurse manager is preparing to institute a new system for scheduling staff
...
Which of the following is an appropriate method to facilitate
the adoption of the new scheduling system?
a
...

b
...

c
...

d
...

31
...
Identify the sequence of actions the nurse
should take
...

Remove the client from the area
...

Activate the first alarm system
...

Confine the fire by closing doors and windows
...

Extinguish the fire if possible
...
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
...

Complete an incident report regarding the breach of the client’s confidentiality
...

Report the possible violation of client confidentiality to the nurse manager
...

Log out the computer so that the client’s son is unable to view his mother’s information
...

Recommend the son meet with the provider to get information about his mother’s condition
...
Nurses on an inpatient care unit are working to help reduce unit costs
...

Return unused supplies from the bedside to the unit’s supply stock
...

Use clean gloves rather than sterile gloves for colostomy care
...

Wait to dispose of sharps containers until they are completely full
...

Store opened bottles of normal saline in a refrigerator for up to 48 hr
...
Which of the following puts a hospital at the highest risk for infringement of client record confidentiality?
a
...

b
...

c
...


d
...

35
...
Which of the following actions should the nurse take
first?
a
...

b
...

c
...

d
...

36
...
Which of the following information should
the nurse include in the report?
a
...
”
b
...
”
c
...
”
d
...
”
37
...
When preparing for discharge the next day, the client states, “It’s okay
...
” Which of the following is the nurse’s priority action?
a
...

b
...

c
...

d
...

38
...

Which of the following strategies should the charge nurse use to assist with negotiations? (SATA)
a
...

b
...

c
...

d
...

e
...

39
...
The nurse should first assess the client
a
...

b
...

c
...

d
...

40
...
She tells the nurse that she slipped and hit
her arm
...

Submit an incident report
...

Alert the client’s provider of the incident
...

Reposition the client to prevent further injury
...

Check the client for injuries
...
A nurse in an acute care unit is assessing a group of clients
...

A client who has pneumonia and has an oxygen saturation of 95%
b
...

A client who has peripheral vascular disease and has +1 pedal pulses bilaterally
d
...
A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg
...
Which of the
following actions should the nurse take?
a
...

b
...

c
...

d
...

43
...

A school-age child has several bruises on her lower legs
...

A preschool child who was previously trained now requires diapers in the hospital
...

A toddler cries whenever his parent enters the hospital room
...

An adolescent admitted to the emergency department won’t speak to his parents
...
A home health nurse is assessing the home environment of a client who is on continuous oxygen therapy
...

The client is covered with a woolen blanket
...

The oxygen machine has a grounded plug
...

The family keeps a spare oxygen tank in the room
...

The windows of the client’s room are open
...
A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids
...

Reddened area on the coccyx
b
...

Glasgow Coma Scale score
d
...
A nurse in the emergency department is caring for a group of four clients
...

A client who has chronic atrial fibrillation and a digoxin level of 0
...

A client who has bleeding esophageal varices and a blood pressure of 90/50 mm Hg
c
...

A client who has chronic kidney disease and a creatinine level of 15 mg/dL
47
...
If things don’t get better, I’m going to
quit
...

“Just stick with it a little longer
...
”
b
...

“You should file a written complaint with hospital administration
...

“I think you have a right to be upset
...
”
48
...
The nurse should recognize that which of the
following can be delegated to assistive personnel?
a
...

Determining the client’s pain level
c
...

Turning the client
49
...
Which of the following tasks can be delegated to an assistive personnel?
a
...

Reviewing dietary instructions for a client with kidney stones
c
...

Obtaining a stool sample from a client with renal failure
50
...
The client expresses
concern about the cost of blood glucose monitoring supplies
...

Case manager
b
...

Chaplain
d
...
A nurse manager is providing orientation to a group of newly licensed nurses
...

Assume leadership for directing the emergency plan
...

Use the chain-of-command for communication
...

Act as a spokesperson between the facility and the community
...

Coordinate the activities of emergency medical services
...
A client who is febrile is admitted to the hospital for treatment of pneumonia
...
Which of the following situations requires the nurse to complete a variance
report with regard to the care pathway?
a
...

b
...

c
...

d
...


53
...
After
problem identification, which of the following actions should the nurse plan to take first as part of the quality
improvement process?
a
...

b
...

c
...

d
...

54
...
Which of the
following conflict-resolution strategies is the nurse manager using?
a
...

Cooperating
c
...

Collaborating
55
...
The newly licensed nurse is having trouble
focusing and has difficulty completing care for his assigned clients
...

Ask other staff members to take over some of his tasks
...

Advise him to complete less time-consuming tasks first
...

Recommend that he take time to plan at the beginning of his shift
...

Offer to provide care for his clients while he takes a break
...
Client satisfaction surveys from a surgical unit indicate that pain is not being adequately relieved during the
first 12 hr postoperatively
...
Which of
the following data sources will be helpful in determining the reason why clients are not receiving adequate pain
management after surgery?
a
...

Pain assessment policy
c
...

Retrospective chart audit
57
...
And it
has been difficult to pay for all the treatments
...

The nurse suggests counseling for the client’s body image issues
...

The nurse investigates potential resources to help the client purchase a wig
...

The nurse informs the next shift nurse regarding the mother’s concerns
...

The nurse explains to the mother that most clients with cancer lose their hair
...
A nurse performing triage during a mass casualty incident should recognize that which of the following clients
should be transported to the hospital first?
a
...

A client who has an open fracture of the femur
c
...

A client who has a penetrating head injury and fixed and dilated pupils
59
...
The nurse requests a consultation
with the wound care specialist
...

Request the consultation after several wound care treatments are tried
...

Arrange the consultation for a time when the nurse caring for the client is able to be present
for the consultation
...

Provide the consultant with subjective opinions and beliefs about the client’s wound care
...

Arrange for the wound care nurse specialist to see the client daily to provide the recommended
treatment
...
Which of the following items must be discarded in a biohazard waste receptacle?
a
...

An empty IV bag removed from a client who has HIV
c
...

A peripheral pad from a client who is 24-hr post-vaginal delivery

61
...
Which of the following nursing
actions is appropriate?
a
...

b
...

c
...

d
...

62
...
Which of the
following should the nurse recognize as containing the essential components of a medication order?
a
...

Multivitamin every morning by mouth
c
...

NPH insulin 10 units before meals and at bedtime
63
...
Which of the following interdisciplinary team members
should be consulted in regard to this client’s care? (SATA)
a
...

Mental health counselor
c
...

Nutritional therapist
e
...
A charge nurse is assessing staff knowledge about safety procedures regarding needlestick injuries
...

“An incident report should be completed if a client receives a stick from her own used needle
...

“I should stop the bleeding as soon as possible following a needlestick injury
...

“Prophylactic treatment should be initiated after a needlestick during preparation of an injection
...

“The needle should be recapped to prevent injury during transport to the biohazard container
...
Which of the following actions taken by a nurse constitutes battery?
a
...

Threatening to apply wrist restraints to control a client who is agitated
c
...

Telling a client who refused his oral medication that he will be given an injection
66
...
Which of
the following actions should the nurse take first?
a
...

b
...

c
...

d
...

67
...
Which of the following tasks is appropriate to assign to a
licensed practical nurse?
a
...

b
...

c
...

b
...

68
...
The nurse should explain that which of the following is an objective of telehealth?
a
...

Providing medication reconciliation
c
...

Establishing communication between providers
69
...
Which of the following actions
should the nurse manager take first?
a
...

b
...

c
...

d
...

70
...
Which of the following is the priority action when creating the discharge plan?

a
...

c
...


Select strategies for cost-effective home care
...

Identify the client’s ability to perform activities of daily living
...


1
...
Several nurses have verbalized
their concern over the possible changes that will occur
...
Identify nurses who accept the change to help influence other staff nurses
...
Provide a brief overview of the scheduling system immediately before its implementation
...
Introduce the new scheduling system by describing how it will save the institution money
...
Offer to reassign staff who do not support the change to another unit
...

A client who is febrile is admitted to the hospital for treatment of pneumonia
...
Which of the following situations requires the nurse to complete a variance
report with regard to the care pathway?
a
...

b
...

c
...

d
...

Rationale: ATI Leadership Page 38, 95, and 222
...


A nurse should recognize that an incident report is required when
a
...

b
...

c
...

d
...

Rationale:ATI Leadership Page 95

4
...

Client satisfaction surveys from a surgical unit indicate that pain is not being adequately relieved during the
first 12 hr post operatively
...
Which of
the following data sources will be helpful in determining the reason why clients are not receiving adequate pain
management after surgery?
a
...
Retrospective chart audit
c
...
Pain assessment policy
Rationale:ATI Leadership Page 19
6
...
The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter
...
“Did you secure the restraints to the side of the rails of the bed?”
b
...
“Did you tie the restraints using a double knot?”
d
...

A nurse is caring for an older adult client who has a stage III pressure ulcer
...
Which of the following actions by the nurse is appropriate when
working with a consultant?
a
...


b
...

c
...

d
...

Rationale: ATI Leadership Page 40
8
...
Which of the following
nursing actions is appropriate?
a
...

b
...
Ensure that admitting staff undergo PPD skin tests
...
Determine who had contact with the client in the last 48 hr
...

A nurse is caring for a client who is unconscious and whose partner is his health care proxy
...
The provider states to the nurse, “I will
not discontinue this client’s treatment
...
” Which
of the following responses by the nurse is appropriate?
a
...
”
b
...
”
c
...
”
d
...
”
Rationale: ATI Leadership Page 54
10
...
Which
of the following information is most important for the nurse to report at shift change?
a
...
Most recent blood glucose reading
c
...
Reddened area on the coccyx
Rationale: ATI Leadership Page 6
11
...
Which of the following clients should the
nurse assets first?
a
...
A client who bas aspiration pneumonia and a respiratory rate of 28/min
c
...
A client who has a clostridium difficile infection and needs a stool specimen collected
Rationale: ATI Leadership Page 7
12
...

The nurse has been unable to reach the provider despite several attempts over the past 30 min
...
Notify the nursing supervisor about the issue
b
...
Apply a warm compress to the hip
d
...
The mother of a client with breast cancer states, “It’s been hard for her, especially after losing her hair
...
” Which of the following actions is appropriate client advocacy?
a
...
The nurse explains to the mother that most client’s with cancer lose their hair
c
...
The nurse suggests counseling for the client’s body image issues

Rationale: ATI Leadership Page 51
14
...
A urinary catheter drainage bag from a client who is postoperative
b
...
A perineal pad from a client who is 24 hr post vaginal delivery
d
...
A nurse tells the unit manager, “I am tired of all the changes on the unit
...
” Which of the following responses by the unit manager is appropriate?
a
...
I think you have a right to be upset
...
just stick with it a little longer
...
you should file a written complaint with hospital administration
Rationale: ATI Leadership Page 23
16
...
telephoning the pharmacy with a prescription for the spouse to pick up
b
...
reporting a client’s disposition to the referring provider
d
...

17
...
Which
of the following actions indicates the nurse is maintaining sterile techniques (select all that apply)`
a
...
rests the cap of solution container upside down on the sterile field
c
...
Places sterile items within a 1
...
5inch) border around the edges of the sterile field
...
A nurse is providing care for four postoperative clients
...
whose pulse has been steadily increasing during the past shift
b
...
whose urine output has averaged 32ml/hr for the past 24hrs
d
...
A nurse is preparing to transcribe a client’s medication prescription in the medical record
...
NPH insulin 10 units before meals and at bedtime
b
...
Multivitamin every morning by mouth
d
...
A nurse is assisting with the orientation of a newly licensed nurse
...
Which of the following interventions is
appropriate?`
a
...
Advise him to complete less time consuming tasks first
c
...
Offer to provide care for his clients while he takes a break
21
...
Which of the following actions should the nurse take first?`
a
...
Irrigate the exposed area with water
c
...
Don personal protective equipment
22
...
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 terminal illness and respirations of 8/m

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
23
...
The nurse should explain that which of the following is an objective of teleheath`
a
...
Providing medication reconciliation
c
...
Developing client treatment protocols
24
...
A nurse clusters documentation of care for multiple clients
b
...
Paper based charts are stored at the nurse’s station
d
...
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
c
...
A nurse places a mask on a client with tuberculosis before transport to the radiology department
26
...
A school age child has several bruises on her lower legs
b
...
An adolescent admitted to the emergency department won’t speak to his parents
d
...
A parish nurse is making referral to a community meal delivery program for a member of the congregation
...
Liaison
b
...
Health educator
d
...
A nurse performing triage during a mass casualty incident should recognize that which of the following clients
should be transported to the hospital first`
a
...
A client who has an open fracture of the femur
c
...
A client who has a penetrating head injury and fixed and dilated pupils
29
...
A nurse manager over hears a provider and a staff nurse talking about a client’s diagnosis in the cafeteria
...
Provide a staff in-service about client confidentiality
...
Report the incident to the nursing supervisor
c
...
Fill out an incident report regarding the situation
...
A client who has substance use disorder is admitted to the mental health unit and reports that he has been
depressed lately
...
Soon everything will be just
fine
...

Ask the client if he has considered hurting himself
...
Provide the client with information about Alcoholics Anonymous
c
...
Reinforce the need to follow up with discharge referral
...
A nurse is caring for a client who reports acute pain but refuses IM medication
...
This illustrates which of the following?
a
...
Battery
c
...
Libel
33
...
Which of the following actions
should the nurse manager take first?`
a
...
Have a blood alcohol level drawn from the nurse
...
Document a factual description of the situation
...
Remove the nurse form the unit
...
A nurse observes a paper bag at the bedside of a client
...
Asthma
b
...
Stridor
d
...
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
...
Laboratory results within the expected reference range
b
...
Date of last bowel movement
d
...
A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift
...
Review the client’s new laboratory values
...
Document assessment data
...
Complete required tasks
d
...

37
...
Which of the following
statements by the newly licensed nurse indicates understanding of isolation guidelines?
a
...
”
b
...
”
c
...
”
d
...
”
38
...
Which of the following tasks is appropriate to delegate
to a licensed practical nurse?
a
...
Referring to a client to social services for assistance with transportation
c
...
Providing the first oral feeding to a client following a stroke
39
...
Which of the following is the priority action when creating the discharge plan? REPEAT
a
...

b
...

c
...

d
...

40
...
Which of the following
clients should the nurse plan to assess first? REPEAT
a
...
A client who has an early morning blood glucose of 220 mg/dL
c
...
A client who is 3 days postoperative and whose dressing has serosanguinous drainage
41
...
Which of the following tasks is appropriate to assign to a
licensed practical nurse? REPEAT
a
...

b
...

C
...

d
...


42
...
The RN
should assign the LPN to the client who requires REPEAT
a
...
Assistance with meals
c
...
Frequent dressing changes
...
Missing
44
...
Which of the following tasks can be delegated to an assistive personnel?
a
...
Reviewing dietary instructions for a client with kidney stones
c
...
Monitoring a client with a fluid restriction
45
...
Which of the following actions should the nurse take
first?
a
...
Remove the restraints from the client’s wrists
c
...
Review the chart for non-restraint alternatives for agitation
46
...
Drug use is suspected in
the crash, and a voided urine specimen is ordered
...
Which of
the following is the appropriate action by the nurse?
a
...
Tell the client that a catheter will be inserted
c
...
Assess the client for urinary retention
47
...
Which of the following is appropriate to
include in the cost-containment plan? REPEAT
a
...
Wait to dispose of sharps container until they are completely full
c
...
Store opened bottles of normal saline in a refrigerator for up to 48 hr
48
...
The nurse should recognize that which of the
following can be delegated to an assistive personnel? REPEAT
a
...
Recording the client’s vital signs
c
...
Checking the pulses of the client’s right food
49
...
Which of the
following conflict-resolution strategies is the nurse manager using? REPEAT
a
...
Collaborating
c
...
Competing
50
...
Which of the following clients should be
assigned to an RN who has floated from a medical-surgical unit?
a
...
A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA
pump
c
...
A client who is at 32 weeks of gestation and has a premature rupture of membranes
51
...
The nurse should schedule an
interdisciplinary conference for which of the following clients?
a
...
2 g/dL

b
...
A client who has orthostatic hypotension and is receiving IV fluids
d
...
com/35490529/ati-normal-range-lab-values-flash-cards/
52
...
Which of
the following statements by a nurse indicates appropriate understanding of these safety procedures? REPEAT
a
...
”
b
...
”
c
...
”
d
...
”
53
...
Which of the following tasks should the nurse assign to the LPN?
a
...
Providing postmortem care for a client who has just died (AP/CNA)
c
...
Reinforcing dietary teaching with a client who has heart disease
54
...
Which of the following actions should the nurse take first?
REPEAT
a
...
Complete an incident report regarding the breach of the client’s confidentiality
c
...
Report the possible violation of client confidentiality to the nurse manager
55
...
Which
of the following findings requires the nurse to intervene?
a
...
The family keeps a spare oxygen tank in the room
c
...
The client is covered with a woolen blanket
56
...
Which of the following instructions
should the nurse include? REPEAT
a
...
Cap the lancet prior to putting it in the trash
c
...
Warm the hands prior to piercing the skin
57
...
The client is
disoriented and has a cardiac arrhythmia
...
Contact the client’s next of kin to obtain consent for treatment
b
...
Have the client sign a consent for treatment
d
...
A client has a new permanent pacemaker inserted
...
The client should avoid using a microwave oven to heat food
b
...
the client should avoid using remote control devices to prevent dysrhythmias
d
...
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
...
Reinforce the potential consequences of not having this information on record to the nursing staff
b
...

c
...
Remind nurses to obtain this information during the admission process
60
...
Which of the following findings should the nurse report to the provider?
REPEAT

a
...
White blood cell count 9,000/mm^3
c
...
Bilateral crackles on auscultation of lungs
61
...
Which of
the following actions should the nurse take first?
a
...
Determining the reasons the nurses are not taking scheduled breaks
c
...
Review facility policies for taking scheduled breaks
62
...
Which of the following interdisciplinary team members
should be consulted in regard to this client’s care? (select all that apply
...
Occupational therapist
b
...
Physical therapist
d
...
Case manager
63
...
Which of the following
statements by a staff nurse indicates that the teaching was effective? REPEAT
a
...
”
b
...
”
c
...
”
d
...
A nurse on a medical-surgical unit is caring for four clients
...
A client who is newly diagnosed with pancreatic cancer and scheduled to begin IV chemotherapy
b
...
A client who is postoperative following a laminectomy 12 hours ago and is unable to void
d
...
A client is scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical units
...
“It’s not too late to cancel the surgery if you want to
...
“This won’t take long and it will be over before you know it
...
“Why did you make the decision to have this procedure?”
d
...
A nurse working in the emergency department is assessing several clients
...
A client who has a raised red skin rash on his arms, neck, and face
b
...
A client who reports shortness of breath and left neck and shoulder pain
d
...
A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility
...
Review current literature regarding client falls
b
...
Notify staff of the increased fall rate
d
...
A nurse is evaluating a newly licensed nurse who is administering a vitamin K
...
Which of the following actions by the newly licensed nurse indicates understanding of the teaching?
(Select all that apply
...
Selects the dorsogluteal site to administer the injections
b
...
Applies gentle pressure at the site after injection
d
...
A nurse enters a client’s room and observes a fire in the trash can
...
(Move all the actions into the box on the right, placing them in the selected order of performance
...
Which of the following actions taken by a nurse constitutes battery?
a
...
Telling a client who refused his oral medication that he will be given an injection
c
...
Threatening to apply wrist restraints to control a client who is agitated



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