Study guide Leadership - Proctored (Complete) Questions With Answers (latest 2020)

LEADERSHIP-PROCTORED LEADERSHIP ⦁ A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly ref ...

LEADERSHIP-PROCTORED LEADERSHIP ⦁ A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse? ⦁ Tell the client that a catheter will be inserted. ⦁ Document the client’s refusal in the chart. ⦁ Assess the client for urinary retention. ⦁ Obtain a provider’s prescription for a blood alcohol level. ⦁ A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? ⦁ Pick up the meal trays after lunch. ⦁ Administer a nasogastric tube feeding. ⦁ Plan break times for assistive personnel. ⦁ Determine adequacy of ventilator settings. ⦁ A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a sterile procedure. Which of the following actions indicates the newly licensed nurse is maintaining sterile technique? (SATA) ⦁ Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field ⦁ Opens the sterile pack by first unfolding the top flap away from her body ⦁ Prepares a container of sterile solution on the field after putting on sterile gloves ⦁ Removes the outside packaging of a sterile instrument before dropping it onto the sterile field ⦁ Holds the sterile solution bottle with the label facing up ⦁ A nurse enters a client’s room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first? ⦁ Auscultate the client’s lungs. ⦁ Notify the provider. ⦁ Place a faulty equipment tag on the pump. ⦁ Complete an incident report. ⦁ A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? ⦁ Reinforcing teaching with a client who is learning to self-administer insulin ⦁ Ambulating a client who is scheduled for discharge later in the day ⦁ Administering morphine IV bolus to a client who is __ hr postoperative ⦁ Admitting a new client who has chronic back pain to the unit ⦁ A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique? ⦁ The nurse applies goggles. ⦁ The nurse turns her back to the sterile field. ⦁ The nurse holds her hands above her waist. ⦁ The nurse puts on a face mask. ⦁ A nurse who is caring for a group of clients delegates collection of vital signs to an assistive personnel (AP). Which of the following actions should the nurse take to evaluate the delegated task? ⦁ 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. ⦁ A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel? ⦁ Obtaining a stool sample from a client who has renal failure ⦁ Monitoring a client who has a fluid restriction ⦁ Assessing a client who just returned from hemodialysis ⦁ Reviewing dietary instructions for a client who has kidney stones ⦁ A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first? ⦁ A client who has a neck injury and is unable to breathe spontaneously ⦁ A client who has two open chest wounds with a left tracheal deviation ⦁ A client who has major burns over 75% of her body surface area ⦁ A client who has bipolar disorder and is exhibiting signs of hallucination (Class 3) ⦁ A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective? ⦁ “A family member can interpret to obtain informed consent from a client who is deaf.” ⦁ “Consent can be given by a durable power of attorney.” ⦁ “Guardian consent is required for an emancipated minor.” ⦁ “The nurse can answer any questions the client has about the procedure.” ⦁ A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee? ⦁ A middle adult client who leaves the facility against medical advice ⦁ An older adult client who has advanced directives on file ⦁ A young adult client who is participating in a medical research study ⦁ An adolescent client whose parents refuse a blood transfusion for religious reasons ⦁ A nurse in an ambulatory care setting is orient a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth? ⦁ Assessing client needs ⦁ Developing client treatment protocols ⦁ Providing medication reconciliation ⦁ Establishing communication between providers (Community Health pg. 75) ⦁ A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes. The client expresses concern about the cost of blood-glucose monitoring supplies. Which of the following actions should the nurse take? ⦁ 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) ⦁ Ask the provider about the possibility of less frequent monitoring (pt needs to monitor often) ⦁ Recommend the client reuse the testing lancets (breaks the safety & infection protocol) ⦁ A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first? ⦁ 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. ⦁ A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management? ⦁ Complete required tasks. ⦁ Review the client’s new laboratory values. ⦁ Determine client care goals (set/plan goals) ⦁ Document assessment data. ⦁ A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which of the following statements by a staff nurse indicates understanding? ⦁ “Clients who participate in research studies forfeit their HIPAA right to privacy.” ⦁ “HIPAA allows facility-specific coding of client health care information to ensure privacy.” ⦁ “HIPAA prohibits the uploading of photographs of client’s providers to social media sites.” ⦁ “HIPAA allows clients to request a review of their own medical records.” ⦁ A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client’s partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done? ⦁ Whether the client understands the risk of refusing the procedure ⦁ Whether the facility ethics committee reached a consensus on the case ⦁ Whether the partner is the client’s durable power of attorney for health care ⦁ Whether the client’s refusal is based on religious belief ⦁ A charge nurse is planning the care of four newborns. An assistive personnel and licensed practical nurse are available for staffing. Which of the following tasks should the nurse assign to a licensed practical nurse? ⦁ Conduct the newborn hearing screening. (RN assessment) ⦁ Administer a hepatitis B vaccine. ⦁ Perform a New Ballard screening. (RN assessment) ⦁ Obtain vital signs. (CNA) ⦁ During a staff meeting a unit manager reviews the results for documenting client education and finds that they are below the benchmark. Which of the following strategies should the nurse manager implement first? ⦁ Train LPNs to reinforce teaching with clients using a standardized teaching plan. ⦁ Determine factors that interfere with the documentation of client education. ⦁ Include documentation of client education as part of unit nurses’ annual performance evaluation. ⦁ Offer incentives for the staff once the unit’s results are back in adherence with the benchmark. ⦁ A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that preventing client injury by removing a fall hazard demonstrates which of the following ethical principles? ⦁ Utility ⦁ Autonomy ⦁ Nonmaleficence ⦁ Veracity ⦁ A nurse is caring for a group of clients. Which of the following clients should the nurse plan to assess first? ⦁ A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past 24 hr (improvement) ⦁ A client who has diabetes mellitus and reports paresthesia in his fingers and toes (ABC--circulation) ⦁ A client who has a nasogastric tube and has crackles in the lungs (ABC--airway) ⦁ A client who has a new diagnosis of Graves’ disease and a TSH level of 0.2 microunits/mL ⦁ A charge nurse is planning to evacuate clients on the unit because there is a fire on another floor. Which of the following clients should the nurse evacuate first? ⦁ A client who is in Buck’s traction for a left hip fracture (can’t necessarily move too much) ⦁ A client who is 1 day postoperative following thoracic surgery and has a chest tube (possible physical instability) ⦁ A client who is confused and restrained for safety (still needs continual nursing care/assessment) ⦁ A client who is receiving IV chemotherapy and is ambulatory ⦁ A nurse enters the room of a client who is unconscious and finds that the client’s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first? ⦁ Recommend the son meet with the provider to get information about his mother’s condition. ⦁ Report the possible violation of client confidentiality to the nurse manager. ⦁ Complete an incident report regarding the breach of the client’s confidentiality. ⦁ Log out the computer so that the client’s son is unable to view his mother’s information. ⦁ A nurse is preparing a client for cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take? ⦁ 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. Which of the following clients should the nurse assess first? ⦁ A client who reports a headache with sensitivity to light ⦁ A client who reports an urge to void but has not urinated during the prior shift ⦁ A client who reports indigestion and pain in her jaw ⦁ A client who reports feeling lightheaded when he stands up from a lying position ⦁ A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? ⦁ Discuss time management strategies with the nurses. ⦁ Determine the reasons the nurses are not taking scheduled breaks. Assess first ⦁ Provide coverage for the nurses’ breaks. ⦁ Review facility policies for taking scheduled breaks. ⦁ A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care? ⦁ Has the AP checked the client’s pain level prior to turning her? (RN only - do not delegate what you can EAT = evaluate, assess, teach) ⦁ Is the client’s family present so the AP can show them how to turn the client? (this is not necessary) ⦁ Has data been collected about specific client needs related to turning? (Assessment of holistic care r/t pt needs and what the experienced AP can do) ⦁ 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. Which of the following information should the nurse include in the background portion of the report? ⦁ A prescribed consultation -under situation ⦁ The client’s vital signs ⦁ The client’s name -under situation ⦁ The client’s code status -under situation ⦁ A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupation therapist is necessary? ⦁ “I need some help planning my meals to maintain my weight.” ⦁ “I am tired of having pain in my joints all the time.” ⦁ “I’m having difficulty climbing the stairs at my house.” ⦁ “I will need assistance with bathing.” ⦁ A nurse in the emergency department is caring for a 16-year-old client who reports abdominal pain and is accompanied by an adult neighbor. The provider diagnoses a ruptured appendix and states that the client requires an emergency appendectomy. Which of the following actions should the nurse? ⦁ Ask the adult neighbor to sign the consent form. ⦁ Obtain consent from the hospital administrator. ⦁ Witness the client signing the consent form. ⦁ Attempt to notify the client’s guardian to obtain consent. ⦁ A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority? ⦁ A client who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds ⦁ A client who has COPD and has an oxygen saturation of 90% ⦁ A client who had a cholecystectomy 6 hr ago and is requesting pain medication ⦁ A client whose TPN was discontinued 4 hr ago and is requesting clear liquids ⦁ A charge nurse suspects that a staff nurse is chemically impaired. Which of the following actions should the charge nurse take? ⦁ Assign clients who are not prescribed narcotics to the staff nurse. ⦁ Collect data about the staff nurse to support further action. ⦁ Report the staff nurse to the facility ethics committee. ⦁ Counsel the staff nurse about substance use. ⦁ A nurse is assessing a client’s comprehension of a pulmonary function test prior to the procedure. Which of the following client statements indicates to the nurse an understanding of the procedure? ⦁ “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.” ⦁ A nurse in the emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first? ⦁ A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood ⦁ An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10 ⦁ An older adult client who has dyspnea and a respiratory rate of 26/min ⦁ An adult client who has large ecchymosis on both legs ⦁ A home health nurse finds piles of newspapers in the hallway of a client’s home. The nurse explains the need to discard the newspapers for safety reasons. The client agrees to move the newspapers into the living room. Which of the following conflict resolution strategies has the nurse used? ⦁ Collaborating ⦁ Smoothing ⦁ Accommodating ⦁ Compromising ⦁ A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to an assistive personnel? ⦁ Advising a client on self-administration of acetaminophen ⦁ Informing a family of a client’s progress in physical therapy ⦁ Teaching a client to perform a finger-stick for testing blood glucose levels ⦁ Performing post mortem care prior to transferring the client to the morgue ⦁ A nurse is providing discharge teaching to a client following a total knee arthroplasty. Which of the following information should the nurse include (SATA) ⦁ Advance directives information ⦁ Contact information for the physical therapist ⦁ Medication guidelines information ⦁ Insurance information ⦁ Information about follow-up care ⦁ A nurse is planning to discharge a client who has terminal cancer and suggests that the family might benefit from respite services. When the client’s partner asks how this service can help, which of the following responses by the nurse is appropriate? ⦁ “This service offers psychological interventions during and after your wife’s illness.” ⦁ “The clinicians help reduce the severity of your wife’s physical problems.” ⦁ “This service delivers meals and supplies to reduce your errands away from home.” ⦁ “It makes it possible for you to have some time away from caring for your wife.” ⦁ A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include? ⦁ Warm the hands prior to piercing the skin. ⦁ Cap the lancet prior to putting it in the trash.- never recap ⦁ Elevate the arm for 1 min before taking the blood sample.- has to be down so gravity can assist to milk the blood out . ⦁ Obtain the blood sample from the finger pads. ⦁ A nurse is assessing a client who had a recent stroke. Which of the following findings should indicate the need for referral to an occupational therapist? ⦁ Receptive aphasia→  unable to understand language in its written or spoken form ⦁ Facial drooping→ speech therapist ⦁ Memory loss ⦁ Unilateral neglect –is one of the disabling features of stroke, and is defined as a failure to attend to the side opposite a brain lesion. ⦁ A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event? ⦁ A network for communication between staff members and families ⦁ A mental health specialist on the response team ⦁ A sufficient supply of personal protective equipment ⦁ A system for tracking client information ⦁ A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department? ⦁ Rotavirus ⦁ Pertussis ⦁ Respiratory syncytial virus ⦁ Group B streptococcal disease ⦁ A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment used for a client who has Clostridium difficile. Which of the following solutions should the nurse recommend to clean the equipment? ⦁ Chlorine bleach ⦁ Triclosan ⦁ Chlorhexidine ⦁ Isopropyl alcohol ⦁ A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take? ⦁ 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 ⦁ A nurse is completing discharge teaching with a client who is being treated for tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? ⦁ “I need to take my prescribed medication for 3 months.” ⦁ “I should have a sputum culture done every 2 to 4 weeks.” ⦁ “I need to have a TB skin test done once per year.” ⦁ “I should wear a mask while around my family.” ⦁ An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to an assistive personnel? ⦁ Checking the pulses of the client’s right foot ⦁ Recording the client’s vital signs ⦁ Turning the client ⦁ Determining the client’s pain level ⦁ A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). Which of the following is an appropriate task for the AP? ⦁ Inspect the skin of a newborn who is receiving phototherapy. – Assess ⦁ Answer the parents’ questions about newborn circumcision. - Teaching ⦁ Show a new mother how to change the newborn’s diaper. - Teaching ⦁ Obtain the weight of a newborn that is receiving formula ⦁ A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? ⦁ “A 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. Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions? ⦁ Mumps ⦁ Rubeola ⦁ Varicella ⦁ Rotavirus ⦁ A nurse is caring for a client who has cancer. The client and her partner are asking the nurse about hospice are. Which of the following statements by the nurse is appropriate? ⦁ “Hospice care will prolong the life expectancy of clients who are terminally ill.” ⦁ “Hospice care is a multidisciplinary program for clients who are terminally ill.” ⦁ “Hospice care is helpful for clients at various stages of chronic illness.” ⦁ “Hospital access is no longer available for clients who are in hospice care.” ⦁ A nurse is planning care for a client who has Addison’s disease. Which of the following tasks should the nurse plan to delegate to an assistive personnel? ⦁ Decide how often to measure vital signs. ⦁ Explain to the client about a 24-hr urine specimen collection. ⦁ Determine the client’s muscle strength prior to ambulation. ⦁ Remind the client to change positions slowly. ⦁ A charge nurse discovers that a staff nurse on the unit has made repeated medication errors. Which of the following actions should the charge nurse take first? ⦁ Notify the risk management department of the situation. (4) ⦁ Review with the nurse the principles of medication administration. (2) ⦁ Ask the nurse to describe her medication administration procedure. (1) ⦁ Identify education opportunities for the nurse regarding safe medication administration. (3) ⦁ A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? P. 42 ch 3 ⦁ Libel : talking bad about someone via writing it in notes ⦁ Battery : intentional/wrongful physical contact   ⦁ Slander : Defamation with the spoken word ⦁ Negligence ⦁ A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client’s ring? ⦁ Place the client’s ring in the facility safe. ⦁ Tape the ring securely to the client’s finger. ⦁ Place the ring in the bad with the client’s clothing. ⦁ Agree to keep the ring for the client until after surgery. ⦁ A nurse is prioritizing postpartum care for four clients. Which of the following actions should the nurse take first? ⦁ Assist a client who requests help breastfeeding her 4-hr-old newborn. ⦁ Administer RH immune globulin to a client who is Rh-negative and 6 hr postpartum. ⦁ Check uterine tone for a client who received methylergonovine- if the uterine tone is not ⦁ 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. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take? ⦁ Withhold the benzodiazepine but continue the opioid. ⦁ Contact the provider about replacing the opioid with an NSAID. ⦁ Administer the benzodiazepine but withhold the opioid. ⦁ Continue the medication dosages that relieve the client’s pain. ⦁ A nurse is observing an assistive personnel (AP) administer 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? ⦁ Administers the solution at room temperature ⦁ Points tubing in the direction of the umbilicus during insertion ⦁ Position the client on her left side with knees flexed ⦁ Inserts the tubing 8 cm (3.1 in) into the rectum ⦁ A nurse is providing information to a client about advance directives. The nurse should explain that advance directives include which of the following? P . 38 ch 3 ⦁ 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 ⦁ Information regarding organ donation ⦁ A form with directions for contacting next of kin ⦁ A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? ⦁ A client who has peripheral vascular disease ad has an absent pedal pulse in the right foot ⦁ 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) ⦁ A client who is postoperative following a laminectomy 12 hr ago and is unable to void ⦁ A staff development nurse is giving an in-service presentation about advocacy in nursing. Which of the following statements by a nurse indicates an understanding of the role of a client advocate? ⦁ “In the role of client advocate, I should take responsibility for coordinating each client’s care.” ⦁ “As a client advocate, I will suggest the best course of action for clients who are indecisive.” ⦁ “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.” ⦁ A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first? ⦁ Refer the AP to the facility procedure manual. ⦁ Instruct the AP to request assistance when unsure about a task. ⦁ Help the AP assist the client with the transfer. ⦁ Demonstrate the proper client transfer technique for the AP. ⦁ A nurse at the local health department is caring for four clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? ⦁ Chlamydia trachomatis ⦁ Pediculosis capitis ⦁ Impetigo contagiosa ⦁ Candida albicans ⦁ A charge nurse witnesses two nurses having a loud discussion at the nurses’ station about not wanting to care for a client who has drug-resistant tuberculosis. Which of the following actions should the charge nurse take? ⦁ Escort the nurses to the nurses’ lounge to continue the discussion. ⦁ Recommend that both nurses be terminated. ⦁ Make arrangements to take over the client’s care. ⦁ Contact the house supervisor to mediate the conflict. ⦁ A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have sufficient experiences to safely care for his assigned clients. Which of the following actions should the nurse take? ⦁ 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. ⦁ A nurse is conducting an in-service about the nursing code of ethics with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching as an example of advocacy? ⦁ Recommending a referral for a client who requires physical therapy ⦁ Suggesting a client’s partner attend a support group for emotional support ⦁ Evaluating a client’s home for safety hazards ⦁ Completing an incident report following a medication error ⦁ A charge nurse in the emergency department is supervising a nurse who is floating from the medical-surgical unit. Which of the following assignments is appropriate for the float nurse? ⦁ 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. ⦁ A home health nurse is assessing the home environment during an initial visit to a client who has history of falls. Which of the following findings should the nurse identify as increasing the client’s risk for falls? (SATA) ⦁ A folding chair without arm rests ⦁ A wheeled office chair at the client’s computer desk ⦁ A throw rug covering some cracked vinyl flooring in the kitchen ⦁ A two-wheeled walker used to assist the client with ambulation ⦁ A raised vinyl seat on the toilet in the bathroom ⦁ A nurse in a long-term care facility should identify that which of the following will provide security for clients who have dementia? ⦁ Turning off room lights at night ⦁ Using a facility ⦁ Restricting space to reduce pacing ⦁ Setting alarms on exits ⦁ A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? ⦁ Have the client sign a consent for treatment ⦁ Notify risk management before initiating treatment ⦁ Proceed with treatment without obtaining written consent (Implied Consent) ⦁ Contact the client’s next of kin to obtain consent for treatment ⦁ A nurse is reviewing the medication administration record of a client and notices that an additional dose of medication has been administered. Which of the following actions should the nurse take first? ⦁ Inform the nursing supervisor. ⦁ Notify the provider ⦁ Observe the client’s condition. ⦁ Complete an incident report. ⦁ A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound care procedure. Which of the following findings indicate wound healing. ⦁ Erythema on the skin surrounding a client's wound ⦁ Deep red color on the center of the clients wound ⦁ Inflammation noted on the tissue edges of a client's wound ⦁ Increase in serosanguineous exudate from the clients wound ⦁ A nurse received change of shift report at 0700 for four clients. Which of the following actions should the nurse perform first? ⦁ Obtain a breakfast tray for a client who received a morning dose of insulin aspart ⦁ Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400 ⦁ Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900 ⦁ Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours. (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. Which of the following clients should the nurse assign to the newly licensed nurse? ⦁ A client who has multiple sclerosis and ataxia ⦁ A client who has brain tumor and is admitted for chemotherapy ⦁ A client who has guillain-barre syndrome and a tracheostomy ⦁ A client who sustained a concussion and is being monitored for complication ⦁ A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? ⦁ “Once I sign my living will, a family member must co sign it” ⦁ “I will wait until I have a serious health problems to sign my advance directives” ⦁ “My doctor will need to provide approval for the decisions outlines in my living will ⦁ “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. Which of the following quality control tasks should the nurse assign to be completed first? ⦁ Identify the industry standards for infant safety ⦁ Evaluate the selected infant safety system ⦁ Choose an infant safety system ⦁ Establish measurement criteria for infant safety systems ⦁ A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform dysphagia screening to determine the client's need for a referral to which of the following providers? ⦁ Physical therapist ⦁ Respiratory therapist ⦁ Speech therapist ⦁ Occupational therapist ⦁ A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls (SATA) [repeat] • A wheeled office chair at the client's computer desk • A raised vinyl seat on the toilet in the bathroom • A throw rug covering some cracked floor • A folding chair without arm rests • A two wheeled walker used to assist the client with ambulation ⦁ A nurse manager is planning to assign care for four clients on a medical surgical unit. Which of the following clients should the nurse assign to a LPN ⦁ An older adult who has lung cancer and has periodic episodes of severe dyspnea ⦁ A middle adult client who has a below the knee amputation and requires a dressing change ⦁ A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus ⦁ 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. Which of the following is the priority for the nurse to take? ⦁ Remind nurses to obtain this information during the admission process ⦁ Reinforce the potential consequences of not having his information on record to the nursing staff ⦁ Meet with nursing staff to review the policy regarding advance directive ⦁ Ask nurse who are caring for client without his information in the medical record to obtain it ⦁ A nurse is caring for a group of clients. Which of the following should the nurse see first? ⦁ A client who is postoperative and has a fever. ⦁ A client whose pressure ulcer has serosanguineous drainage on the dressing ⦁ A client who has diabetes mellitus and is diaphoretic ⦁ A client who has a fractured hip and reports a pain level of 7 on a scale from 0-10 ⦁ A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse care for first? ⦁ A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg ⦁ A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea ⦁ A client who has pneumonia and requires a tracheostomy dressing change ⦁ 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. Which of the following actions should the nurse manager take first? ⦁ Acknowledge the conflict and encourage the nurses to focus on working as a team ⦁ Gather information regarding the situation ⦁ Encourage the nurses to resolve the conflict autonomously ⦁ Meet with a committee from each shift to discuss issues related to the conflict ⦁ A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first? ⦁ Don personal protective equipment ⦁ Irrigate the exposed area with water ⦁ Remove the client’s clothing ⦁ Report the incident to OSHA ⦁ A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first? ⦁ Complete an incident report ⦁ Measure the client’s vital signs ⦁ Inform the nurse manager ⦁ Call the provider ⦁ A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately? ⦁ Decreased level of consciousness ⦁ Generalized rash over trunk ⦁ Increased temperature ⦁ Report of photophobia ⦁ A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway? ⦁ Antibiotic therapy was initiated 2 hr after implementation of the care pathway. ⦁ A blood culture was obtained after antibiotic therapy had been initiated ⦁ An allergy to penicillin required an alternative antibiotic to be prescribed ⦁ The route of antibiotic therapy on the care pathway was changed from IV to PO ⦁ A nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager assign to a float nurse from the medical-surgical unit? ⦁ A client who is post term and is receiving oxytocin for labor induction ⦁ A client who gave birth to her first child and requires instruction on breastfeeding techniques ⦁ A client who is 2 days post-operative following a caesarean birth and is having difficulty ambulating ⦁ A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion ⦁ A nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following members of the interprofessional team should the nurse consult? ⦁ Risk management coordinator ⦁ Clinical pharmacist ⦁ Nursing supervisor ⦁ Infection control nurse ⦁ A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take? ⦁ Discuss with the client her concerns regarding the procedure ⦁ Provide the client with information on treatment options and outcomes ⦁ Inform the client of the consequences of uterine prolapse and the need for intervention ⦁ Initiate a mental health consult to determine the client’s reasons for refusing surgery ⦁ A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? ⦁ Delay the surgery until the nurse can obtain informed consent ⦁ 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. Which of the following tasks should the nurse plan to delegate to an assistive personnel? ⦁ Performing postmortem care prior to transferring the client to the morgue ⦁ Advising a client on self-administration of acetaminophen ⦁ Teaching a client to perform a finger-stick for testing blood glucose levels ⦁ Informing a family of a client’s progress in physical therapy ⦁ A nurse is working on a quality improvement team that is assessing an increase in client fall at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? ⦁ Notify staff of the increased fall rate ⦁ Review current literature regarding client falls ⦁ Implement a fall prevention plan ⦁ Identify clients who are at risk of falls ⦁ A nurse is completing performance evaluation for an assistive personnel (AP). Which of the following actions by the AP requires intervention by the nurse? ⦁ 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. Which of the following is priority action by the charge nurse? ⦁ Assess the staff nurse’s knowledge deficit. ⦁ 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. ⦁ A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which of the following tasks should the nurse assign to the AP? ⦁ Administer the initial bolus feeding to a client who has NG tube ⦁ Check a client pain level 30min after receiving acetaminophen ⦁ Collect urine specimen for newly admitted client ⦁ Instruct a client to splint an abdominal incisions ⦁ A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a client. Which of the following actions should the nurse take? ⦁ Treat the client’s injuries within 30 min ⦁ Provide treatment for life-threatening injuries ⦁ Provide treatment for minor injuries ⦁ Allow the client to die without further intervention ⦁ A home health nurse is performing a safety assessment of a client’s home. Which of the following findings should the nurse identify as a safety hazard? ⦁ The client has used tracks to secure the carpet on the stairs ⦁ The client’s electrical cord is taped to the floor ⦁ The client’s bedside lamp is plugged in using an extension cord with two prongs ⦁ The client stores cleaning supplies in a locked cabinet above his head ⦁ A charge nurse is observing a newly licensed nurse provide care for a client who has Clostridium difficile infections. Which of the following actions by the newly licensed nurse indicate an understanding of proper infection control procedures? ⦁ Applies a mask before entering the client’s room (It’s contact precaution) ⦁ Removes fresh flowers from the client’s room.   ⦁ Washes her hands with an alcohol-based hand rub after caring for the client.(no, ineffective and must wash hands with soap/water) ⦁ Wears gown when caring for client ⦁ A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client’s need for which of the following supplies to manage tracheostomy at home? (SATA) ⦁ Pipe cleaners ⦁ O2 Tank ⦁ Cotton balls ⦁ Petroleum Jelly ⦁ Obturator ⦁ A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent? ⦁ An adult client who has alcohol intoxication- NOT FOCUSED ⦁ An adolescent client who is legally emancipated ⦁ An older adult client who has questions about the procedure= having questions means you dont understand, ⦁ An adult client who has moderate Alzheimer’s disease.- cant consent if you are not FOCUSED ⦁ A nurse is discussing the safekeeping of valuables with a client who is scheduled for surgery. Which of the following client statements indicates the need for further teaching? ⦁ “I can wear my ankle bracelet since i am just having a local anesthetic: ⦁ “I can leave my wedding ring on if it is taped in place” ⦁ “I should remove my dentures before the procedure” ⦁ “I should leave my valuables with a family member” ⦁ A nurse is caring for an older adult client who has Stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant? ⦁ Request the consultation after several wound care treatments are tried ⦁ Arrange for the wound care nurse specialist to see the client daily to provide the recommended treatments ⦁ 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 ⦁ A nurse is observing an AP administer 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? ⦁ Positions the client on her left side with knees flexed ⦁ Administers the solution at room temp ⦁ Points tubing in the direction of the umbilicus during insertion ⦁ Inserts the tubing 8cm (3.1 in) into the rectum ⦁ A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? ⦁ “I should encrypt personal health information when sending emails.” ⦁ “I can post the client’s vital signs in the client’s room.” ⦁ “I can use another nurse’s password as long as I log off after using the computer” ⦁ “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. Which of the following is an appropriate resource for the nurse to consult in planning for this policy? (2016 practice) ⦁ ANA Standards of Practice ⦁ ANA Code of Ethics ⦁ State Nurse Practice Act ⦁ Institute of medicine ⦁ A charge nurse observe a licensed practical nurse tell a client that she will return with a medication to help relieve the client’s nausea. The LPN does not return with the medication. The charge nurse should reinforce which of the following ethical principles with the LPN? ⦁ Veracity ⦁ Justice- ⦁ Fidelity ⦁ Nonmaleficence ⦁ A nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take? ⦁ Use root cause analysis to identify gaps in meeting standards- root cause analysis is done if the benchmark is not met ⦁ Establish work initiatives to promote a positive environment ⦁ Compare practices within the facility against other high-performing facilities ⦁ 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. Which of the following actions should the nurse take first? ⦁ Place a faulty equipment tag on the pump ⦁ Notify the provider ⦁ Auscultate the client’s lungs ⦁ Complete an incident report ⦁ A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response? ⦁ “It’s not too late to cancel the surgery if you want to” ⦁ “Why did you make the decision to have this procedure?” ⦁ “This won’t take long and it will be over before you know it” ⦁ “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. Which of the following infections should the nurse report to the public health department? ⦁ Lyme disease ⦁ Bacterial conjunctivitis ⦁ Health care-acquired pneumonia ⦁ MRSA ⦁ A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report? ⦁ The steps to follow when providing wound care ⦁ The client’s preferred time for bathing ⦁ The belief that the client has a difficult relationship with his son ⦁ The time the client received his last dose of pain medication ⦁ A nurse receives a new prescription over the telephone from a client’s provider. Which of the following actions should the nurse take first ⦁ Write down the complete prescription ⦁ Read back the prescription to the provider ⦁ Document the prescription as a telephone prescription in the medical record ⦁ Ensure that the provider signs the prescription ⦁ A charge nurse witnessed an assistive personnel failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first? ⦁ Discuss the issue with the AP ⦁ Notify the unit manager about the incident ⦁ Reinforce facility protocols at the next staff meeting ⦁ Alert the infection control department ⦁ A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan? ⦁ Raise all four side rails on the client’s bed ⦁ Remove the clock and calendar from the client’s room ⦁ Obtain a prescription for a sedative for the client ⦁ Provide distractions for the client during the day ⦁ A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take? ⦁ Initiate contact precautions (standard) ⦁ Report the infection to the local health department ⦁ Apply an antiviral cream to lesions ⦁ Instruct the client to use condoms until the treatment is completed (NO, not 100% preventable) ⦁ A nurse is teaching a class of newly licensed nurses about evidence-based practices. The nurse should include which of the following as the first step in evidence-based practice? ⦁ Apply research to client care practice ⦁ Develop a clinical question ⦁ Critically assess the evidence ⦁ 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. As clients arrive at the designed triage area outside the hospital, which of the following actions should the nurse take? ⦁ Place shower caps over the client's’ hair ⦁ Remove contaminated clothing ⦁ Scrub the client’s skin with betadine solution ⦁ Admit the injured clients to positive-pressure rooms ⦁ A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? ⦁ Libel ⦁ Negligence ⦁ Battery ⦁ Slander ⦁ A nurse is preparing to complete morning assignments on several assigned clients. Which of the following clients should the nurse plan to assess first? ⦁ A client who had a bladder scan that indicated 250 mL of urine in the bladder ⦁ A client who is 3 days postoperative and who’s dressing has serosanguinous drainage ⦁ A client who has diabetes and an early morning blood glucose of 220 mg/dL ⦁ A client who has a nasogastric tube to intermittent suction and reports nausea ⦁ A charge nurse overhears a staff nurse discussing a client’s diagnosis in the cafeteria. Which of the following responses should the charge nurse make? ⦁ “Please stop discussing the client in a public area” ⦁ “Do you understand the HIPAA regulations?” ⦁ “We should discuss your concerns with the client’s care team” ⦁ “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. Which of the following actions should the nurse preceptor identify as maintaining sterile technique? ⦁ Places sterile gauze 1.3cm (0.5 in) away from the edge of a sterile drape ⦁ Uses sterile forceps to pack sterile gauze into the wound ⦁ Sets up the sterile field 30 min prior to performing the dressing change ⦁ Uses a sterile-gloved hand to adjust the back of the sterile gown. ⦁ A nurse working in a long-term care facility is assessing an older adult client who has been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the following actions should the nurse take? ⦁ Place the client in a negative-pressure airflow room ⦁ Perform hand hygiene with alcohol based hand sanitizer. ⦁ Clean the equipment in the client’s room with bleach. ⦁ Initiate droplet precautions for the client. ⦁ A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate? ⦁ Advise him to complete the less time consuming tasks first ⦁ Recommend that he take time to plan at the beginning of his shifts ⦁ Offer to provide care for his clients while he take a break ⦁ Ask other staff members to take over some of his tasks ⦁ A nurse is planning discharge for a client who has lung resection. The nurse initiates a referral for a social worker. Which of the following assessment data supports this referral? ⦁ The client needs to have someone bring O2 tanks and equipment to her home ⦁ The client needs to have range-of-motion exercises to assist with ambulation ⦁ The client needs to arrange financial resources to purchase equipment ⦁ The client needs to have someone come in to help her bathe at home ⦁ A nurse initiates a referral to an occupation therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for this referral? ⦁ The client reports pain when chewing solid foods. ⦁ The client expresses the desire to join a support group. ⦁ The client requires assistance with completing oral hygiene ⦁ The client has difficulty ambulating with a walker ⦁ A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client’s care? (SATA) ⦁ Nutritional therapists ⦁ Case Manager ⦁ Mental Health counselor ⦁ Occupational therapist ⦁ Physical therapist ⦁ A nurse is prioritizing care after a receiving change-of-shift report on four clients. Which of the following clients should the nurse assess first? [repeat] ⦁ A client who reports a headache with sensitivity to light. ⦁ A client who reports feeling lightheaded when he stands up from a lying position ⦁ A client who reports indigestion and pain in her jaw ⦁ 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. Which of the following clients is the highest priority? ⦁ A client who has depressive disorder and has poor personal hygiene ⦁ A client who has dementia and exhibits aphasia ⦁ A client who has bipolar disorder and displays constant pacing – (Can lead to physical exhaustion and death) ⦁ A client who has schizophrenia and uses neologisms ⦁ A nurse is planning care for a group of clients. Which of the following action should the nurse take first? ⦁ 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. Which of the following responses should the nurse make? ⦁ “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. The client refuses two of the medications, stating, “I’ve never taken these before.” Which of the following actions should the nurse take first? ⦁ Consult the pharmacist about the client’s prescribed medications. ⦁ Compare the client’s medication administration record with the prescriptions on the transfer orders. ⦁ Review the intended purpose of the prescribed medication with the client. ⦁ Call the provider to clarify the clients prescribed medications. ⦁ A nurse on a med surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? ⦁ A client who is postoperative following laminectomy 12hrs ago is unable to void ⦁ A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy ⦁ A client who has peripheral vascular disease and has an absent pedal pulse in the right foot ⦁ A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38C (101F) ⦁ A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take? ⦁ Plan to administer an antiviral medication to the client. ⦁ Wear an N95 respirator mask while caring for the client. ⦁ Prepare to administer antibiotics to the client. ⦁ Place a surgical mask on the client during transfer to the unit. ⦁ A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? [repeat] ⦁ Discuss the time management strategies with the nurses ⦁ Review facility policies for taking scheduled breaks. ⦁ Provide coverage for the nurses’ breaks ⦁ Determine the reasons the nurses are taking scheduled breaks. ⦁ A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? ⦁ False imprisonment ⦁ Libel ⦁ Assault ⦁ Battery ⦁ A nurse is speaking with a visitor who asks a questions about the status of a relative who is a fadovclient on the unit. Which of the following responses by the nurse is appropriate? ⦁ “I’m not taking care of your relative today, so I don’t have the latest information” ⦁ “I will have your relative’s nurse come and talk with you about her care.” ⦁ “Let me check your relative’s medical record to see how she’s doing.” ⦁ “Please ask your relative about this, because I cannot share information about her.” ⦁ A nurse suggests respite care for the partner of a client who has mild cognitive impairment. The client’s partner asks the nurse how that would help. The nurse should explain the respite care would do which of the following? ⦁ Allow her to take time off from attending to her partner ⦁ Provide volunteers who will run errands for her ⦁ Send a clinician to assess the safety of leaving her partner alone ⦁ Help her arrange transferring her partner to an assisted living facility ⦁ A charge nurse observes a client fall during ambulation and notes that his gait belt was not in place. In reviewing the incident report, the nurse finds no mention of a gait belt. Which of the following ethical principles should guide the nurse’s subsequent actions? ⦁ Non maleficence - do no harm ⦁ Veracity - commitment to tell the truth ⦁ Fidelity - keep promises ⦁ Beneficence - promote good for others ⦁ A nurse is caring for a client who is scheduled for placement of a central venous access device. Which of the following actions is the nurse’s responsibility in the informed consent process? ⦁ Place a photocopy of the signed consent in the client’s medical record ⦁ Review the risks and benefit of the procedure with the client ⦁ Discuss alternative treatment options with the client ⦁ Assess the client’s understanding after the provider has talked with her ⦁ A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching? ⦁ Remove the client’s restraints every 2 hr. ⦁ Allow 1 fingerbreadth between the restraint and the client’s wrists ⦁ Attach the restraints to the fixed portion of the frame of the client’s bed ⦁ Secure the client’s restrains with a square knot ⦁ A nurse is preparing an educational program for staff members 2 a new intravenous pump. Identify the sequence of actions the nurse should taken when developing the program. (Move the steps into the box on the right, placing them in order of performance). ·    Determine what skills to teach the staff members - 1 ·    Develop learning objectives for the program - 2 ·    Identify resources available to meet objectives - 3 ·    Review the staff member’s evaluation of the program - 4 2.  A nurse suggest respite care for the partner of a client who has mild impairment. The client’s partner asks the nurse how that would help. The nurse should explain that respite care would do which of the following? ⦁ Allow her to take time off attending to her partner 3. A case manager observes a family member of a client who has Alzheimer’s disease throwing books on the floor and sobbing while the client is having a diagnostic test. Which of the following actions should the case manager take first? ⦁ Offer to have a brief talk with the caregiver 4. A nurse is caring for a client who has early stage Alzheimer’s disease. In which of the following actions is the nurse acting as a client advocate? ⦁ Requesting a referral for the client to attend reminiscent therapy sessions 5. A nurse manager is reviewing the nursing code of ethics with the staff nurses. Which of the following statements by a staff nurse indicate understanding of the teaching (SATA). ⦁ “I will attend continuing education classes for professional growth.” ⦁ “I can delegate the removal of an IV catheter to an LPN on the unit.” ⦁ “I administer pain medication to my clients even if they have a history of narcotic addiction.” 6. A nurse is discussing advance directives with a client. 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.” 7. A nurse is caring for a client who has a pressure ulcer on the coccyx. Which of the following findings indicated the need for referral to a wound care specialist? ⦁ Presence of slough in the wound bed 8. A nurse on a medical-surgical unit delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel? ⦁ Suctioning a client’s long-term tracheostomy 9. A nurse is providing teaching about infection control measures to a client who has an indwelling urinary catheter. Which of the following instructions should the nurse include in the teaching? ⦁ Use sterile technique to collect specimens from the drainage system 10. A nurse manager is preparing an in-service for a group of staff nurses about organ donation. Which of the following information should the manager include? ⦁ Nurses may witness the signing of organ donation consents 11. A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response? ⦁ “It’s not too late to cancel the surgery if you want to.” [repeat] 12. A charge nurse is observing a newly licensed nurse insert an NG tube and connect it to a suction source. Which of the following actions by the newly licensed nurse demonstrates an understanding of the process? ⦁ Clamps the air vent tubing 13. A nurse working in an emergency department is performing triage. 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. A nurse receives change-of-shift report for the following four clients. 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. A charge nurse is making assignments for a medical surgical unit. 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. A nurse is admitting a client who is scheduled for cholecystectomy. The client does not speak English and is accompanied by her adult daughter. Which of the following actions should the nurse take? ⦁ Access a language line to interpret what is being said 17. A nurse is caring for a client who has an MI. The client’s daughter ask the nurse to review her father’s medical with her. Which of the following responses should the nurse make? ⦁ “Your father will have to give permission for you to review the record.” 18. A nurse is teaching a client who requires protective isolation due to immune system compromise. Which of the following instructions should the nurse include to protect the client? “Make sure your visitors wear a gown when they are in your room.” “Wear gloves and a gown whenever you need to leave your room.” “Be sure to eat plenty of fresh fruit and vegetables.” 19. A nurse in the emergency department is preparing a married 17-year-old client for an appendectomy. The client’s parents are en route to the facility but have not spoken with the surgeon. Which of the following actions should the nurse take? ⦁ Have the client sign the consent form after the surgeon explains the procedure 20. A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate? ⦁ “I understand, and it’s not too late to change your mind.” 21. A nurse is completing discharge teaching with a client who is being treated with tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? ⦁ “I should have a sputum culture done every 2-4 weeks” 22. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client’s need for which of the following to manage the tracheostomy at home? (SATA) ⦁ Obturator ⦁ Oxygen tank ⦁ Suction machine 23. A nurse is completing discharge teaching about dietary supplements for nitrogen loss with a client who has cancer. Which of the following nutrients should the nurse recommend the client increase? ⦁ Protein 24. A case manager is preparing a client who has a spinal cord injury for discharge from the rehabilitation setting to home. Which of the following actions is the case manager’s priority when creating the discharge plan? ⦁ Facilitate client referrals for community resources 1. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first? o   Establish measurement criteria for infant safety systems. o   Evaluate the selected infant safety system. o   Choose an infant safety system. o   Identify the industry standards for infant safety. 2. A nurse at a local health department is caring for four clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? o   Chlamydia trachomatis o   Pediculosis capitis o   Impetigo contagiosa o   Candida albicans 3. A nurse at a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department. o   Candidiasis o   Gonorrhea o   Trichomoniasis o   Human papillomavirus 4. A charge nurse discovers that a staff nurse on the unit has made repeated medication errors. Which of the following actions should the charge nurse take first? o   Review with the nurse principles of medication administration. o   Ask the nurse to describe the medication administration procedure. o   Identify education opportunities for the nurse regarding safe medication administration. o   Notify the risk management department of the situation. 5. The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. 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. A nurse is working with a committee that is performing an annual review of policies and procedures. After gathering data, identify the sequence the committee should follow when using the stages of change. (put in order) o   Determine goals 1 o   Create a revised protocol 2 o   Implement the revised protocol 3 o   Review the results of the provisions.   4 7. A nurse is providing a change of shift report for the oncoming nurse. 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 is the president of a local bank.” o   “ The client will need vital signs checked every 4 hours.” o   “ The client is currently in the radiology department for a chest x-ray.” 8. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend? o   Child protective services o   Pharmacist o   Social worker o   Respiratory therapist 9. A nurse is preparing a shift assignment for an assistive personnel on the unit. Which of the following tasks should the nurse assign to the AP? o   Check a client’s pain level 30 min after receiving acetaminophen o   Administer the initial bolus feeding to a client who has an NG tube o   Collect a urine specimen from a newly admitted client o   Instruct a client to splint an abdominal incision 10.  A nurse is teaching a class of newly licensed nurses about evidence- based practice. The nurse should include which of the following as a first step in 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.  A nurse is inspecting a clients IV pump prior to use. 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.  A nurse who is caring for a group of clients, delegates collection of vital signs to an assistive personnel. 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   Ask the AP to write a summary of the delegated tasks during the shift. o   Compare the vital signs the AP obtained with those taken by another AP on a previous shift. 13.  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. The client states, “The tumor is on the right side of my head.” Which of the following actions should the nurse take? o   Continue with the surgery because the client already gave informed consent. o   Ask the surgeon to clarify the operative site with the client o   Contact the surgery department to validate the operative site o   Tell the client to mark the right side of his head with indelible ink 14.  A nurse is preparing to witness a client’s signature on an informed consent for a surgical procedure. Which of the following actions is the nurse’s responsibility? o   Ensuring the client appears competent to consent to the procedure o   Discussing options for the alternative therapies with the client o   Providing the client with a complete description of the procedure o   Explaining the risks associated with the procedure to the client 15.  A charge nurse witnesses two nurses having a loud discussion at the nurses’ station about not wanting to care for a client who has drug-resistant tuberculosis. Which of the following actions should the charge nurse take? o   Make arrangements to take over the clients care. 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.  A nurse is observing an assistive personnel administer 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? o   Inserts the tubing 8 cm (3.1 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. Position the client on the left side with the right leg flexed forward. Slowly insert the rectal tube 7.5 to 10 cm (3 to 4 in). 17.   A nurse is prioritizing care after receiving report on four clients. 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.  A charge nurse is directing the unit nurses to implement the emergency response plan for a fire on the unit. 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. 19.  A nurse is providing teaching to an older adult client regarding home safety. Which of the following instructions should the nurse include in the teaching? o   Cover chords with the carpet to prevent falls o   Unplug humidifier before cleaning it o   Change batteries in the smoke alarm every 2 years o   Set the water heater to 60 degrees C (140 F) 20.  A nurse is using the SBAR communication tool while giving report on a client. The nurse should include the client’s pain level after receiving a PRN dose of morphine 1 hr ago during which part of the report? o   A-assessment o   B-background o   R-recommendation o   S-situation 21.   A nurse is comparing the rate of medication errors on the medical unit to the rate from a medical unit in a magnet hospital. Which of the following quality improvement methods is the nurse using? o   Benchmarking o   Structure audit o   Risk benefit analysis o   Root cause analysis 22.  A nurse is planning a discharge for a client who has a new diagnosis of COPD and lives alone. Which of the following actions is the nurse’s priority? o   Provide printed materials for new prescriptions o   Set up appointments in in-home physical therapy o   Request a referral for a home safety assessment o   Suggest participating in a community group 23.  A nurse is caring for a group of clients. Which of the following clients should the nurse see first? o   A client who is postoperative and has a fever (nonurgent) o   A client who has a fractured hip and reports a pain level of 7 on a scale of 0 to10 o   A client who has pressure ulcer has serosanguineous drainage on the dressing o   A client who has diabetes mellitus and is diaphoretic 24.  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. The nurse manager should identify that which of the following torts has occurred? o   Negligence o   Battery o   Libel o   Slander 25.  A nurse initiates a referral to an occupational therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for the referral? o   The client has difficulty ambulating with a walker o   The client requires assistance with completing oral hygiene o   The client reports pain when chewing on solid foods o   The client expresses desire to join a support group 26.  A home health nurse finds piles of newspaper in the hallway of a client’s home. The nurse explains the need to discard the newspapers for safety reasons. The client agrees to move the newspapers into the living room. Which of the following conflict resolution strategies has the nurse used? o   Compromising o   Smoothing o   Collaborating o   Accommodating 27.  A nurse reports to a charge nurse that a client’s visitor slipped and fell. The visitor denies any injury and is walking around. 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.  A nurse is preparing an education program about professional codes of ethics for nurses. 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.  An infection control nurse is planning an education program for a group of newly licensed nurses. Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions? o   Rotavirus o   Rubeola o   Varicella o   Mumps 30.  A nurse manager discovers there is a conflict between nurses working day shift and working night shift. 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.  A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique? 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.  A nurse in an emergency department is triaging four clients. 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 (0.79 in) head laceration oozing dark red blood o   An older adult client who has dyspnea and a respiratory rate of 26min o   An adult client who has large ecchymoses on both legs 33.  A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance? o   Pharmacist o   Occupational therapist o   Respiratory therapist o   Physical therapist   34.  A nurse in a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include? o   Accompany residents older than 85 years of age during ambulation o   Institute rounds every 2 hr during the day to offer toileting o   Keep the four side rails up on beds at night o   Apply vest restraints on residents who are confused 35.  A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change of shift report? o   The time the client received his last dose of pain medication o   The clients preferred bath time o   The belief that the client has a difficult relationship with his son o   The steps to follow when providing wound care 36.  A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent? o   An adult client who has moderate Alzheimer’s disease o   An older adult client who has questions about the procedure o   An adult client who has alcohol intoxication o   An adolescent client who is legally emancipated 37.  A nurse is completing a performance evaluation for an assistive personnel. Which of the following actions by the AP requires intervention by the nurse? o   The AP wears a mask when caring for a client who has varicella o   The AP removes cut flowers from the room of a client who is in a protective environment o   The AP closes the door of a client who is on airborne precaution o   The AP uses alcohol hand antiseptic after caring for a client who has C-Diff 38.  A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee? o   A young adult client who is participating in a medical research study o   An older adult client who has advance directives on file o   An adolescent client whose parents refuse a blood transfusion for religious reasons o   A middle adult client who leaves the facility against medical advice 39.  A nurse is working with a licensed practical nurse (LPN) to care for a group of clients. Which of the following clients should the nurse delegate to the LPN? o   A client who has leukemia and requires an updated plan of care o   A client who is transferring from the PACU following abdominal hernia repair o   A client who has type 1 diabetes mellitus and receives insulin before meals o   A client who requires discharge teaching about a newly described medication- 40.  A nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of MRSA. Which of the following members of the interprofessional team should the nurse consult? o   Infection control nurse o   Nursing supervisor o   Risk management coordinator o   Clinical pharmacist 41.  A charge nurse provides an annual in-service for the nursing staff regarding ethical practice. Which of the following actions should the nurse include as an example of ethical practice? o   A nurse raises all four side rails on the bed of a client who is confused o   A nurse refuses to care for a client who has had an abortion o   A nurse withholds nutrition from a client who has DNR order - don’t do this... o   A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min. 42.  A nurse is conducting an in service about the nursing code of ethics with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching as an example of advocacy? o   Evaluating a client’s home for safety hazards o   Recommending a referral for a client who requires physical therapy o   Completing an incident report following a medication error o   Suggesting a client’s partner attend a support group for emotional support 43.  A nurse enters a client’s room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first? o   Notify the provider o   Place a faulty equipment tag on the pump o   Auscultate the client’s lungs o   Complete and incident report 44.  A nurse is documenting and completing an incident report after a client falls out of bed. Which of the following actions should the nurse take when completing the documentation? o   Document in the incident report, ‘ Entered room and discovered client lying prone on the floor’ o   Document in the nurses report, ‘Photocopy of incident report sent to risk management’ o   Document in incident report, ‘Client found lying on the floor after falling out of bed’ o   Document in nurses notes, ‘Incident report completed and filed’ 45.  A nurse is planning discharge teaching for a client who has a newly placed tracheostomy tube. The nurse should assess the client’s need for which of the following supplies to manage tracheostomy at home? (SATA) o   Cotton-twill tracheostomy ties o   Suction machine o   Povidone – iodine swabs o   Petroleum jelly lubricated gauze o   Oxygen tank 46.  A nurse is providing discharge teaching to a client following total knee arthroplasty. Which of the following information should the nurse include? (SATA) o   Information about follow up care o   Medication guideline information o   Advance directives information o   Contact information for the physical therapist o   Insurance information 47.  A charge nurse overhears a staff nurse discussing a client’s diagnosis in the cafeteria. Which of the following responses should the charge nurse make? o   “ We should discuss your concerns with the client’s care team” o   “ I will need to notify the client’s provider about the breach of confidentiality” o   “ Please stop discussing the client in a public area” o   “ Do you understand HIPAA regulations?” 48.  A nurse is caring for a client who reports taking a new herbal supplement after reading about it on the Internet. Which of the following instructions should the nurse provide the client? o   Compare website’s information with a variety of sources o   Look for medical information on network (. 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.  A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that preventing client injury by removing a fall hazard demonstrates which of the following ethical principles? 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.  A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take? o   Tell the client to leave her purse in a drawer of the bedside table o   Place the purse in the clothing bag with the clients belongings o   Offer to place the purse in the facility’s safe o   Offer to store the purse in the nurses station 51.  A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse is appropriate? o   Elevating the head of the bed 20 degree angle o   Check residual volume before each feeding o   Flushing The tube with 15 mL of water o   Adding colored food dye to the formula 52.  A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client’s risk of falls? (SATA) o   A throw rug covering some cracked vinyl flooring in the kitchen o   A folding chair without arm rests o   A two- wheeled walker used to assist the client with ambulation o   A raised vinyl seat on the toilet in the client’s bathroom o   A wheeled office chair at the client’s computer desk 53.  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. Which of the following responses should the nurse make? o   “ It is necessary for an attorney to approve your health care proxy” o   “ A health care proxy can make decisions for you when you are unable to do so” o   “ You must choose a member of your family to serve as your health care proxy” o   “ You should appoint a health care proxy before undergoing an invasive procedure” 54.  A nurse is preparing to transfer a client to the radiology department using the wheelchair. Which of the following actions should the nurse take? o   Push the wheelchair into the elevator, large wheels last/ o   Leave a transfer belt in place until the client returns from radiology o   Keep the footplates lowered throughout the transfer process. o   Test the locks on both wheels of the chair prior to transfer. 55.  A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the in-service? o   “A nurse can apply restraints on a PRN basis” o   “A nurse can administer medications without consent to a client as part of a research study” Patients have right to refuse o   “A nurse can disclose information to a family member with the client’s permission.” o   “A nurse is responsible for informing clients about treatment options” 56.  A charge nurse suspects that a staff nurse is chemically impaired. 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.  A charge nurse is admitting a client who speaks a different language than the nurse and will require and interpreter. 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.  A nurse is caring for a client who has Addison’s disease. 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.  A nurse is caring for a client who had a stroke and is experiencing difficulty swallowing. 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.  A nurse is planning care for four clients who were classified using a disaster triage tag team system following a mass casualty event. 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.  A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take? o   File an incident report o   Ask the client about his injuries with the son present o   Treat and discharge the client o   Ask the client’s son to wait in the waiting room 62.  A charge nurse is reviewing the actions by a nurse following a client fall. Which of the following actions by the nurse requires intervention by the charge nurse? o   Lists names of witnesses to the fall in the incident report o   Documents in the client’s record, “Incident report was filed” o   Sends the incident report to risk management o   Includes the client’s account of the fall in the incident report 63.  A nurse on a medical-surgical unit is making staff assignments. Which of the following tasks should the nurse delegate to an assistive personnel? o   Pouching a client’s established ostomy o   Reinforcing teaching with a client about low-sodium diet o   Demonstrating the use of an incentive spirometer to a client o   Updating a family member about a client’s condition 64.  A nurse is caring for a client who is scheduled for placement of central venous access device. Which of the following actions is the nurse’s responsibility in the informed consent process? o   Discuss alternative treatment options with the client o   Place a photocopy of the signed informed consent in the client’s medical record - o   Assess the client’s understanding after the provider has talked to her o   Review the risks and benefits of the procedure with the client 65.  A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? o   “ A provider can write a prescription for restraints ‘as needed’ o   “ I should tie the restraints using a square knot” o   “ I need to tie the restraint to the part of the bed frame that moves” o   “ I will remove the client’s restraints every 4 hours” 66.  A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse care for first? o   A client has pneumonia and requires a tracheostomy dressing change o   A client has a new colostomy and requires discharge teaching o   A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea o   A client who is 4 hours postoperative following a hernia repair and has pitting edema of the right leg – (Compartment syndrome) 67.  A charge nurse is receiving change of shift report. Which of the following situations should the charge nurse report address first? o   Transport assistance is unavailable to take a client to occupational therapy o   The emergency department nurse is waiting to give report on a new admission o   A nurse on the previous shift wrote an incident report on a medication error o    Two staff members have called to say there were absent 68.  A nurse is providing information to a client about advance directives. The nurse should explain that advance directions include which of the following? o   Instructions regarding treatments the client desires or does not desire o   Information regarding organ donation o   Information regarding the disposition of the client’s body upon death o   A form with directions for contacting next of kin 69.  A nurse is reviewing medication administration record of a client and notices that an additional dose of medication has been administered. Which of the following actions should the nurse make first? o   Inform the nursing supervisor o   Notify the provider o   Complete an incident report o   Observe the client’s condition 70.  A nurse is assessing a client who has meningitis. Which of the following finding should the nurse report to the provider immediately? o   Increased temperature o   Report of photophobia o   Decreased level of consciousness o   Generalized rash over trunk 1.     A nurse is evaluating a newly licensed nurse who is administering a vitamin K injection to a newborn. Which of the following actions by the newly licensed nurse indicates understanding of the teaching? (SATA) ⦁ Applies gentle pressure at the site after injection ⦁ Aspirates the syringe for blood return after needle insertion ⦁ Selects the dorsogluteal site to administer the injection ⦁ Inserts the needle at a 45° angle - IM should be 90 ⦁ Cleans the injection site with alcohol Rationale: https://www.atitesting.com/ati_next_gen/skillsmodules/content/medication-administration-3/equipment/intramuscular-injections.html 2.     A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective? ⦁ “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.” 3.     A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include? ⦁ 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.     A client is admitted with COPD. Which of the following findings should the nurse report to the provider? ⦁ Report of dyspnea on exertion ⦁ Oxygen saturation 89% on room air ⦁ White blood cell count 9,000/mm3 d.     Bilateral crackles on auscultation of lungs 5.     A client schedule for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response? ⦁ “You shouldn’t be worried because the procedure is very safe.” ⦁ “This won’t take long and it will be over before you know it.” ⦁ “Why did you make the decision to have this procedure?” ⦁ “It’s not too late to cancel the surgery if you want to.” 6.     A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? ⦁ Libel ⦁ False imprisonment ⦁ Battery ⦁ Assault 7.     A nurse manager overhears a provider and a staff nurse talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first? ⦁ Provide a staff inservice about client confidentiality. ⦁ Fill out an incident report regarding the situation. ⦁ Remind them that client information is confidential. ⦁ Report the incident to the nursing supervisor. 8.     A nurse is serving on a committee that is revising the protocol for discharging clients. After developing an initial plan, in which order should the nurse take the following steps? ⦁ Determine goals ⦁ Implement recommended strategies ⦁ Revise the plan. ⦁ Evaluate the results 9.     A nurse is orienting to an emergency department. The nurse is asked to assist with suturing of a laceration on a client’s hand. Which of the following is the best resource for this nurse? ⦁ The preceptor on the clinical unit ⦁ The provider suturing the client’s injury ⦁ The nursing supervisor ⦁ The information on the suture package 10.   A client is brought to the emergency department (ED) following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse? ⦁ Assess the client for urinary retention. ⦁ Obtain a provider’s prescription for a blood alcohol level. ⦁ Tell the client that a catheter will be inserted. ⦁ Document the client’s refusal in the chart. 11.    While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take? ⦁ Ask nurses who are caring for clients without this information in the medical record to obtain it. ⦁ Remind nurses to obtain this information during the admission process. ⦁ Meet with nursing staff to review the policy regarding advance directives. ⦁ Reinforce the potential consequences of not having this information on record to the nursing staff. 12.   A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management? ⦁ Determine client care goals. ⦁ Review the client’s new laboratory values. ⦁ Complete required tasks. ⦁ Document assessment data. 13.   A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed? ⦁ A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min. ⦁ A nurse refuses to actively participate during an elective abortion procedure scheduled for her client. ⦁ A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better. ⦁ A nurse explains to a client’s family that a DNR includes withholding comfort measures. 14.   A nurse is caring for a client who is unconscious and whose partner is his health care proxy. The partner has spoken with the provider and wishes to discontinue the client’s feeding tube. The provider states to the nurse, “I will not discontinue this client’s treatment. His partner has no right to make decisions regarding the client’s care.” Which of the following responses by the nurse is appropriate? ⦁ “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.” 15.   A parish nurse is making a referral to a community meal delivery program for a member of the congregation. This is an example of which of the following functions of the parish nurse? ⦁ Health educator ⦁ Liaison ⦁ Pastoral care provider ⦁ Personal health counselor 16.   A nurse is preparing to discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the following information should the nurse include in the verbal transfer report? ⦁ Laboratory results within the expected reference range ⦁ Level of consciousness ⦁ List of regularly prescribed medications ⦁ Date of last bowel movement 17.   A charge nurse on a postpartum unit is teaching a client who gave birth 2 hr ago about the facility’s protocols for preventing newborn abduction. Which of the following instructions should the nurse include? ⦁ “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.” 18.   A nurse is assigned the following four clients for the current shift. Which of the following clients should the nurse assess first? ⦁ A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot ⦁ A client who has a hip fracture and is in Buck’s traction ⦁ A client who has aspiration pneumonia and a respiratory rate 28/min ABC ⦁ A client who has a Clostridium difficile infection and needs a stool specimen collected 19.   A nurse should recognize that an incident report is required when ⦁ A visitor pinches his finger in the client’s bed frame. ⦁ A nurse gives a medication 30 min late. ⦁ A client throws a box of tissues at a nurse. ⦁ A client refuses to attend physical therapy. 20.   A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practical nurse? ⦁ Referring a client to social services for assistance with transportation ⦁ Providing the first oral feeding to a client following a stroke ⦁ Instructing a client who is obese about a low-fat diet ⦁ Changing the dressing on a postoperative wound 21.   A nurse is precepting a newly licensed nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurse ask? ⦁ “Are you removing the client’s restraints every 4 hours?” ⦁ “Are you able to insert two fingers between the restraints and the client’s skin?” ⦁ “Did you tie the restraints using a double knot?” ⦁ “Did you secure the restraints to the side rails of the bed?” 22.   A nurse observes a paper bag at the bedside of a client. This finding suggests that the client is receiving treatment for which of the following respiratory disorders? ⦁ Stridor ⦁ Asthma ⦁ Hyperventilation ⦁ Atelectasis 23.   Which of the following observations requires a charge nurse to intervene and demonstrate safe handling techniques? ⦁ A nurse uses goggles to perform tracheostomy suctioning. ⦁ A nurse places a mask on a client with tuberculosis before transport to the radiology department. ⦁ A nurse cleans up a blood spill with a 1:10 bleach solution. ⦁ A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen. 24.   A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a sterile procedure. Which of the following actions indicates the nurse is maintain sterile technique? (SATA) ⦁ Opens the sterile pack by first unfolding the flap farthest from her body ⦁ Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field ⦁ Places sterile items within a 1.25-cm (0.5-inch) border around the edges of the sterile field ⦁ Removes the outside packaging of a sterile instrument before dropping it onto the sterile field e.      Rests the cap of a solution container upside down on the sterile field 25.   A nurse working on a medical-surgical unit is receiving shift report regarding four clients. Which of the following client should the nurse see first? ⦁ A 75-year-old man who has pneumonia and has a O2 saturation of 92% ⦁ A 80-year-old woman who has a urinary tract infection and a temperature of 38.2° C (100.8° F) ⦁ A 45-year-old man who has new onset of confusion 24 hr after a total hip arthroplasty ⦁ A 50-year-old woman reporting abdominal pain of 7 on a scale of 0 to 10 26.   An RN is planning client assignments for a licensed practical nurse (LPN) and three assistive personnel. The RN should assign the LPN to the client who requires ⦁ Recording of daily intake and output ⦁ Assistance with meals ⦁ A complete bed bath ⦁ Frequent dressing changes 27.   A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include? ⦁ 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. 28.   According to HIPAA regulations, which of the following is a violation of client confidentiality? ⦁ Reporting a client’s disposition to the referring provider ⦁ Informing housekeeping staff that the client is in the dialysis unit ⦁ Providing a copy of the record to the transporting paramedic ⦁ Telephoning the pharmacy with a prescription for the spouse to pick up 29.   A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client’s need for which of the following to manage the tracheostomy at home? (SATA) ⦁ Pipe cleaners ⦁ Cotton balls ⦁ Petroleum jelly ⦁ Oxygen tank ⦁ Obturator 30.   A nurse manager is preparing to institute a new system for scheduling staff. Several nurses have verbalized their concern over the possible changes that will occur. Which of the following is an appropriate method to facilitate the adoption of the new scheduling system? ⦁ Provide a brief overview of the new scheduling system immediately before its implementation. ⦁ Offer to reassign staff who do not support the change to another unit. ⦁ Identify nurses who accept the change to help influence other staff nurses. ⦁ Introduce the new scheduling system by describing how it will save the institution money. 31.   A nurse enters a client’s room and observes a fire in the trash can. 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. 32.   A nurse enters the room of a client who is unconscious and finds that the client’s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first? REPEAT ⦁ 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. 33.   Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan? ⦁ 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. 34.   Which of the following puts a hospital at the highest risk for infringement of client record confidentiality? ⦁ Paper-based charts are stored at the nurses’’ station. ⦁ A provider and nurse access client information using once access code. ⦁ A nurse performs electronic documentation outside a client’s room. ⦁ A nurse clusters documentation of care for multiple clients. 35.   A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first? ⦁ Review the chart for non-restrain alternatives for agitation. ⦁ Speak with the AP about the incident. ⦁ Remove the restraints from the client’s wrists. ⦁ Inform the unit manager of the incident. 36.   A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report? ⦁ “The client’s partner came to visit him 2 hours ago and smelled of alcohol.” ⦁ “The client is currently in the radiology department for a chest x-ray.” ⦁ “The client will need vital signs every 4 hours.” ⦁ “The client is the president of a local bank.” 37.   A client who has substance use disorder is admitted to the mental health unit and reports that he has been depressed lately. When preparing for discharge the next day, the client states, “It’s okay. Soon everything will be just fine.” Which of the following is the nurse’s priority action? ⦁ Ask the client if he has considered hurting himself. ⦁ Provide the client with information about Alcoholics Anonymous. ⦁ Encourage the client to participate in physical activities. ⦁ Reinforce the need to follow up with discharge referral. 38.   A charge nurse is addressing conflict between two nurses who are having a disagreement at the nurses’ station. Which of the following strategies should the charge nurse use to assist with negotiations? (SATA) ⦁ Continue negotiations until a resolution is made. ⦁ Have the nurses move the discussion to a private location. ⦁ Begin negotiations with minimal demands from each nurse. ⦁ Address the nurses using assertive communication techniques. ⦁ Use active listening when obtaining each nurse’s perception of the situation. 39.   A nurse is providing care for four postoperative clients. The nurse should first assess the client ⦁ Who is reporting nausea after the prescribed antiemetic was administered. ⦁ Whose pulse has been steadily increasing during the past shift. ⦁ Whose urine output has averaged 32 mL/hr for the past 24 hr. ⦁ Who is reporting a pain level of 8 on a scale of 0 to 10. 40.   A nurse finds a client sitting on the floor holding her right forearm. She tells the nurse that she slipped and hit her arm. Which of the following actions should the nurse take first? ⦁ Submit an incident report. ⦁ Alert the client’s provider of the incident. ⦁ Reposition the client to prevent further injury. ⦁ Check the client for injuries. 41.   A nurse in an acute care unit is assessing a group of clients. Which of the following clients is the nurse’s priority? ⦁ A client who has pneumonia and has an oxygen saturation of 95% ⦁ A client who has atrial fibrillation and reports chest pain of 5 on a scale from 0 to 10 ⦁ A client who has peripheral vascular disease and has +1 pedal pulses bilaterally ⦁ A client who has inflammatory bowel syndrome and reports two loose stools 42.   A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take? ⦁ Reposition the client for comfort. ⦁ Notify the nursing supervisor about the issue. ⦁ Contact the client’s physical therapist. ⦁ Apply a warm compress to the hip. 43.   Which of the following should lead a nurse to suspect abuse that must be reported? ⦁ 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. 44.   A home health nurse is assessing the home environment of a client who is on continuous oxygen therapy. Which of the following findings requires the nurse to intervene? ⦁ 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. 45.   A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following information is most important for the nurse to report at shift change? ⦁ Reddened area on the coccyx ⦁ Most recent blood glucose reading ⦁ Glasgow Coma Scale score ⦁ Laboratory tests scheduled for next shift 46.   A nurse in the emergency department is caring for a group of four clients. Which of the following clients should the nurse recommend for transfer to the ICU? ⦁ A client who has chronic atrial fibrillation and a digoxin level of 0.3 ng/mL ⦁ A client who has bleeding esophageal varices and a blood pressure of 90/50 mm Hg ⦁ A client who has a head injury and Glasgow Coma Scale score of 10 ⦁ A client who has chronic kidney disease and a creatinine level of 15 mg/dL 47.   A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t get better, I’m going to quit.” Which of the following responses by the unit manager is appropriate? ⦁ “Just stick with it a little longer. Things will get better soon.” ⦁ “So you are upset about all the changes on the unit?” ⦁ “You should file a written complaint with hospital administration.” ⦁ “I think you have a right to be upset. I am tired of the changes, too.” 48.   An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to assistive personnel? ⦁ Recording the client’s vital signs ⦁ Determining the client’s pain level ⦁ Checking the pulses of the client’s right foot ⦁ Turning the client 49.   A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel? ⦁ Assessing a client who just returned from hemodialysis ⦁ Reviewing dietary instructions for a client with kidney stones ⦁ Monitoring a client with a fluid restriction ⦁ Obtaining a stool sample from a client with renal failure 50.   A nurse is providing teaching to a client who has a new diagnosis of diabetes mellitus. The client expresses concern about the cost of blood glucose monitoring supplies. Which of the following referrals should the nurse make to address the client’s concern? ⦁ Case manager ⦁ Dietitian ⦁ Chaplain ⦁ House supervisor 51.   A nurse manager is providing orientation to a group of newly licensed nurses. The nurse manager should communicate that which of the following actions is the responsibility of the nurse when responding to a disaster? ⦁ 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. 52.   A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway? ⦁ A blood culture was obtained after antibiotic therapy had been initiated. ⦁ The route of antibiotic therapy on the care pathway was changed from IV to PO. ⦁ An allergy to penicillin required an alternative antibiotic to be prescribed. ⦁ Antibiotic therapy was initiated 2 hr after implementation of the care pathway. 53.   A nurse is working on a quality improvement team that is assessing an increase in client falls at a facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? ⦁ Review current literature regarding client falls. ⦁ Identify clients who are at risk for falls. ⦁ Notify staff of the increased fall rate. ⦁ Implement a fall prevention plan. 54.   To receive a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies is the nurse manager using? ⦁ Compromising ⦁ Cooperating ⦁ Competing ⦁ Collaborating 55.   A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate? ⦁ 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. 56.   Client satisfaction surveys from a surgical unit indicate that pain is not being adequately relieved during the first 12 hr postoperatively. The unit manager decides to identify postoperative pain as a quality indicator. Which of the following data sources will be helpful in determining the reason why clients are not receiving adequate pain management after surgery? ⦁ Prospective chart audit ⦁ Pain assessment policy ⦁ Postoperative care policy ⦁ Retrospective chart audit 57.   The mother of a client with breast cancer states, “It’s been hard for her, especially after losing her hair. And it has been difficult to pay for all the treatments.” Which of the following actions is appropriate client advocacy? ⦁ 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. 58.   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 client who has a 4-inch laceration on the forearm ⦁ A client who has an open fracture of the femur ⦁ A client who reports substernal chest pain radiating to the neck ⦁ A client who has a penetrating head injury and fixed and dilated pupils 59.   A nurse is caring for an older adult client who has a Stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant? ⦁ 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. 60.   Which of the following items must be discarded in a biohazard waste receptacle? ⦁ A bedsheet from a client with bacterial pneumonia ⦁ An empty IV bag removed from a client who has HIV ⦁ A urinary catheter drainage bag from a client who is postoperative ⦁ A peripheral pad from a client who is 24-hr post-vaginal delivery 61.   A client is admitted with tuberculosis and placed in a negative pressure room. Which of the following nursing actions is appropriate? ⦁ Notify the local health department of the admission. ⦁ Ensure that admitting staff undergo PPD skin tests. ⦁ Place a sign on the client’s door with the diagnosis. ⦁ Determine who had contact with the client in the last 48 hr. 62.   A nurse is preparing to transcribe a client’s medication prescription in the medical record. Which of the following should the nurse recognize as containing the essential components of a medication order? ⦁ Haloperidol 1 mg by mouth ⦁ Multivitamin every morning by mouth ⦁ Aspirin 650 mg by mouth every 4 hr ⦁ NPH insulin 10 units before meals and at bedtime 63.   A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client’s care? (SATA) ⦁ Case manager ⦁ Mental health counselor ⦁ Physical therapist ⦁ Nutritional therapist ⦁ Occupational therapist 64.   A charge nurse is assessing staff knowledge about safety procedures regarding needlestick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safety procedures? ⦁ “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.” 65.   Which of the following actions taken by a nurse constitutes battery? ⦁ Failing to put up side rails on a confused client’s bed ⦁ Threatening to apply wrist restraints to control a client who is agitated ⦁ Inserting a feeding tube against the wishes of a client who refuses to eat ⦁ Telling a client who refused his oral medication that he will be given an injection 66.   A charge nurse notices that two staff nurses are not taking meal breaks during their regular 8-hr shifts. Which of the following actions should the nurse take first? ⦁ Provide coverage for the nurses’ breaks. ⦁ Discuss time management strategies with the nurses. ⦁ Determine the reasons the nurses are not taking scheduled breaks. ⦁ Review facility policies for taking scheduled breaks. 67.   A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? ⦁ Determine adequacy of ventilator settings. ⦁ Plan break times for assistive personnel. ⦁ Administer a nasogastric tube feeding. ⦁ Pick up the meal trays after lunch. 68.   A nurse is an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth? ⦁ Assessing client needs ⦁ Providing medication reconciliation ⦁ Developing client treatment protocols ⦁ Establishing communication between providers 69.   A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the following actions should the nurse manager take first? ⦁ Remove the nurse from the unit. ⦁ Have a blood alcohol level drawn from the nurse. ⦁ Report the situation to the director of nursing. ⦁ Document a factual description of the situation. 70.   A case manager working in a rehabilitation unit is discharging to home a client who has a spinal cord injury at vertebral level C-7. Which of the following is the priority action when creating the discharge plan? ⦁ Select strategies for cost-effective home care. ⦁ Provide educational handouts related to care requirements. ⦁ Identify the client’s ability to perform activities of daily living. ⦁ Recommend community resources available to assist with client care. 1. A nurse manager is preparing to institute a new system for scheduling staff. Several nurses have verbalized their concern over the possible changes that will occur. Which of the following is an appropriate method to facilitate the adoption of the new scheduling system? a. Identify nurses who accept the change to help influence other staff nurses. b. Provide a brief overview of the scheduling system immediately before its implementation. c. Introduce the new scheduling system by describing how it will save the institution money. ATI Leadership Page 36 d. Offer to reassign staff who do not support the change to another unit. 2. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway? a.     Antibiotic therapy was initiated 2 hr after implementation of the care pathway. b.     A blood culture was obtained after antibiotic therapy had been initiated. c.     The route of antibiotic therapy on the care pathway was changed from IV to PO. d.     An allergy to penicillin required an alternative antibiotic to be prescribed. Rationale: ATI Leadership Page 38, 95, and 222. 3. A nurse should recognize that an incident report is required when a.     A client refuses to attend physical therapy. b.     A visitor pinches his finger in the client’s bed frame. c.     A client throws a box of tissues at a nurse. d.     A nurse gives a medication 30 min late. Rationale:ATI Leadership Page 95 4. MISSING 5. Client satisfaction surveys from a surgical unit indicate that pain is not being adequately relieved during the first 12 hr post operatively. The unit manager decides to identify postoperative pain as a quality indicator. Which of the following data sources will be helpful in determining the reason why clients are not receiving adequate pain management after surgery? a.     Prospective chart audit b.     Retrospective chart audit c.     Postoperative care policy d.     Pain assessment policy Rationale:ATI Leadership Page 19 6. A nurse is precepting a newly licensed nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurse ask? a.     “Did you secure the restraints to the side of the rails of the bed?” b.     “Are you able to slip two fingers between the restraints and the client’s skin?” c.     “Did you tie the restraints using a double knot?” d.     “Are you removing the client’s restraints every 4 hours?” Rationale: ATI Leadership Page 81 7. A nurse is caring for an older adult client who has a stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant? a.     Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation. b.     Provide the consultant with subjective opinions and beliefs about the client’s wound care. c.     Request the consultation after several wound care treatments are tried. d.     Arrange for the wound care nurse specialist to see the client daily to provide the recommendation treatment. Rationale: ATI Leadership Page 40 8. A client is admitted with tuberculosis and placed in a negative pressure room. Which of the following nursing actions is appropriate? a.     Notify the local health department of the admission. b.     Place a sign on the client’s door with the diagnosis c.     Ensure that admitting staff undergo PPD skin tests. d.     Determine who had contact with the client in the last 48 hr. Rationale:ATI Leadership Page 62 9. A nurse is caring for a client who is unconscious and whose partner is his health care proxy. The partner has spoken with the provider and wishes to discontinue the client’s feeding tube. The provider states to the nurse, “I will not discontinue this client’s treatment. His partner has no right to make decisions regarding the client’s care.” Which of the following responses by the nurse is appropriate? a.     “You should consider speaking with the facility’s ethics committee before making your decision.” b.     “You have the right to make that decision, even if the partner is the client’s health care proxy.” c.     “The client has designated his partner as health care proxy in his advanced directives.” d.     “We’ll need to have the nursing supervisor review the client’s advanced directives.” Rationale: ATI Leadership Page 54 10.  A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following information is most important for the nurse to report at shift change? a.     Glasgow coma scale score b.     Most recent blood glucose reading c.     Laboratory tests scheduled for next shift d.     Reddened area on the coccyx Rationale: ATI Leadership Page 6 11.  A nurse is assigned the four following client’s for the current shifts. Which of the following clients should the nurse assets first? a.     A client who has a hip fracture and is in buck’s traction b.     A client who bas aspiration pneumonia and a respiratory rate of 28/min c.     A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot d.     A client who has a clostridium difficile infection and needs a stool specimen collected Rationale: ATI Leadership Page 7 12.  A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take? a.     Notify the nursing supervisor about the issue b.     Contact the client’s physical therapist c.     Apply a warm compress to the hip d.     Reposition the client for comfort Rationale: ATI page 15 13.  The mother of a client with breast cancer states, “It’s been hard for her, especially after losing her hair. And it has been difficult to pay for all the treatments.” Which of the following actions is appropriate client advocacy? a.     The nurse investigates potential resources to help the client purchase a wig b.     The nurse explains to the mother that most client’s with cancer lose their hair c.     The nurse informs the next shift nurse regarding the mother’s concerns d.     The nurse suggests counseling for the client’s body image issues Rationale: ATI Leadership Page 51 14.  Which of the following items must be discarded in a biohazard waste receptacle? a.     A urinary catheter drainage bag from a client who is postoperative b.     A bed sheet from a client with bacterial pneumonia c.     A perineal pad from a client who is 24 hr post vaginal delivery d.     An empty IV bag removed from a client who has HIV Rationale:ATI Leadership Page 75 15.  A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t get better, I’m going to quit.” Which of the following responses by the unit manager is appropriate? a.     so you are upset about all the changes on the unit b.     I think you have a right to be upset. I am tired of changes too c.     just stick with it a little longer. Things will get better soon d.     you should file a written complaint with hospital administration Rationale: ATI Leadership Page 23 16.  According to HIPPA regulation, which of the following is a violation of client confidentiality?` a.     telephoning the pharmacy with a prescription for the spouse to pick up b.     providing a copy of the record to the transporting paramedi c c.     reporting a client’s disposition to the referring provider d.     informing housekeeping staff that the client is in the dialysis unit. 17.  A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with sterile procedure. Which of the following actions indicates the nurse is maintaining sterile techniques (select all that apply)` a.     opens the sterile pack by first unfolding the flap farthest from her body b.     rests the cap of solution container upside down on the sterile field c.     holds a bottle of sterile solution 15cm (6 inches) above the sterile field d.     Places sterile items within a 1.25cm (.5inch) border around the edges of the sterile field. 18.  A nurse is providing care for four postoperative clients. The nurse should assess the client` a.     whose pulse has been steadily increasing during the past shift b.     who is reporting pain level of 8 on a scale of 0-10 c.     whose urine output has averaged 32ml/hr for the past 24hrs d.     Who is reporting nausea after the prescribed antiemetic was administered 19.  A nurse is preparing to transcribe a client’s medication prescription in the medical record. Which of the following should the nurse recognize as containing the essential components o f a medication order a.     NPH insulin 10 units before meals and at bedtime b.     Haloperidol(Haldol)1mgbymouth c.     Multivitamin every morning by mouth d.     Aspirin 650mg by mouth every 4 hours 20.  A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?` a.     Recommend that he take time to plan at the beginning of his shift b.     Advise him to complete less time consuming tasks first c.     Ask other staff members to take over some of his tasks d.     Offer to provide care for his clients while he takes a break 21.  A nurse is in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first?` a.     Remove the clients clothing b.     Irrigate the exposed area with water c.     Report the incident to OSHA d.     Don personal protective equipment 22.  A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed` a.     A nurse refuses to actively participate during an elective abortion procedure scheduled for her client b.     A nurse gives prescribed opioids to a client who has terminal illness and respirations of 8/m c.     A nurse explains to a client’s family that DNR orders includes withholding comfort measures d.     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.  A nurse in an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of teleheath` a.     Assessing client needs b.     Providing medication reconciliation c.     Establishing communication between providers d.     Developing client treatment protocols 24.  Which of the following puts a hospital at the highest risk for infringement of client record confidentiality?` a.     A nurse clusters documentation of care for multiple clients b.     A provider and nurse access client information using one access code c.     Paper based charts are stored at the nurse’s station d.     A nurse performs electronic documentation outside a client’s room 25.  Which of the following observations requires a charge nurse to intervene and demonstrate safe handling techniques` a.     A nurse cleans up a blood spill with a 1:10 bleach solution b.     A nurse uses goggles to perform tracheostomy suctioning c.     A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen d.     A nurse places a mask on a client with tuberculosis before transport to the radiology department 26.  Which of the following should lead a nurse to suspect abuse that must be reported?` a.     A school age child has several bruises on her lower legs b.     A toddler cries whenever his parent enters the hospital room c.     An adolescent admitted to the emergency department won’t speak to his parents d.     A preschool child who previously toilet trained now requires diapers in the hospital 27.  A parish nurse is making referral to a community meal delivery program for a member of the congregation. This is an example of which of the following functions of the parish nurse` a.     Liaison b.     Pastoral care provider c.     Health educator d.     Personal health counselor 28.  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 reports substernal chest pain radiating to the neck b.     A client who has an open fracture of the femur c.     A client who has a 4 inch laceration on the forearm d.     A client who has a penetrating head injury and fixed and dilated pupils 29.  MISSING 30.  A nurse manager over hears a provider and a staff nurse talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first? a.     Provide a staff in-service about client confidentiality. b.     Report the incident to the nursing supervisor c. Remind them that client information is confidential d.     Fill out an incident report regarding the situation. 31.  A client who has substance use disorder is admitted to the mental health unit and reports that he has been depressed lately. When preparing for discharge the next day, the client states, “It’s okay. Soon everything will be just fine.” Which of the following is the nurse’s priority action?` a. Ask the client if he has considered hurting himself. b.     Provide the client with information about Alcoholics Anonymous c.     Encourage the client to participate in physical activities d.     Reinforce the need to follow up with discharge referral. 32.  A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? a.     False imprisonment b.    Battery c.     Assault d.     Libel 33.  A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the following actions should the nurse manager take first?` a.     Report the situation to the director of nursing b.     Have a blood alcohol level drawn from the nurse. c.     Document a factual description of the situation. d.     Remove the nurse form the unit. 34.  A nurse observes a paper bag at the bedside of a client. The finding suggests that a client is receiving treatment for which of the following respiratory disorders? ` a.     Asthma b.     Hyperventilation c.     Stridor d.     Atelectasis 35.  A nurse is preparing to discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the following information should the nurse include in the verbal transfer report?` a.     Laboratory results within the expected reference range b.     List of regularly prescribed medications c.     Date of last bowel movement d. Level of consciousness 36.  A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management?` a.     Review the client’s new laboratory values. b.     Document assessment data. c.     Complete required tasks d.     Determine client care goals. 37.  A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines? a.     “I will instruct visitors to wear a mask when visiting a client who is on contact precautions.” b.     “I will place a client who has compromised immunity in a negative-pressure airflow room.” c.     “I will wear a N95 respirator mask when caring for a client who is on droplet precautions.” d.     “I will have a client who is on airborne precautions wear a mask when out of her room.” 38.  A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practical nurse? a. Changing the dressing on a postoperative wound b.     Referring to a client to social services for assistance with transportation c.     Instructing a client who is obese with a low-fat diet d.     Providing the first oral feeding to a client following a stroke 39.  A case manager working in a rehabilitation unit is discharging to home a client who has a spinal cord injury at vertebral level C-7. Which of the following is the priority action when creating the discharge plan? REPEAT a.     Select strategies for cost-effective home care. b. Identify the client’s ability to perform activities of daily living. c.     Provide educational handouts related to care requirements. d.     Recommend community resources available to assist with client care. 40.  A nurse is preparing to complete morning assessments on several assigned clients. Which of the following clients should the nurse plan to assess first? REPEAT a.     A client who has a nasogastric tube to intermittent suction and reports nausea b.     A client who has an early morning blood glucose of 220 mg/dL c.     A client who had a bladder scan that indicated 250 mL of urine in the bladder d.     A client who is 3 days postoperative and whose dressing has serosanguinous drainage 41.  A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? REPEAT a.     Plan break times for assistive personnel. b.     Pick up the meal trays after lunch. C.    Administer a nasogastric tube feeding. d.     Determine adequacy of ventilator settings. 42.  A RN is planning client assignments for a licensed practical nurse (LPN) and three assistive personnel. The RN should assign the LPN to the client who requires REPEAT a.     Recording of daily intake and output b.     Assistance with meals c.     A complete bed bath d.     Frequent dressing changes. 43.  Missing 44.  A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel? a.     Assessing a client who just returned from hemodialysis b.     Reviewing dietary instructions for a client with kidney stones c.     Obtaining a stool sample from a client with renal failure d.     Monitoring a client with a fluid restriction 45.  A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first? a.     Inform the unit manager of the incident b.     Remove the restraints from the client’s wrists c.     Speak with the AP about the incident d.     Review the chart for non-restraint alternatives for agitation 46.  A client is brought to the emergency department (ED) following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse? a.     Document the client’s refusal in the chart REPEAT b.     Tell the client that a catheter will be inserted c.     Obtain a provider’s prescription for the blood alcohol level d.     Assess the client for urinary retention 47.  Nurses on an in-patient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan? REPEAT a.     Use clean gloves rather than sterile gloves for colostomy care b.     Wait to dispose of sharps container until they are completely full c.     Return unused supplies from the bedside to the unit’s supply stock d.     Store opened bottles of normal saline in a refrigerator for up to 48 hr 48.  An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to an assistive personnel? REPEAT a.     Turning the client b.     Recording the client’s vital signs c.     Determining the client’s pain level d.     Checking the pulses of the client’s right food 49.  To resolve the conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies is the nurse manager using? REPEAT a.     Compromising b.     Collaborating c.     Cooperating d.     Competing 50.  A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit? a.     A client who has gestational diabetes and is receiving biweekly nonstress tests b.     A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump c.     A multigravida client who has preeclampsia and is receiving mistoprostol (Cytotec) for induction of labor d.     A client who is at 32 weeks of gestation and has a premature rupture of membranes 51.  A nurse working on a medical-surgical unit is managing care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients? a.     A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL b.     A client who has Type 1 diabetes and uses an insulin pump c.     A client who has orthostatic hypotension and is receiving IV fluids d.     A client who is receiving heparin and has an aPTT of 34 seconds (On heparin: 45-80 sec) Rationale: https://quizlet.com/35490529/ati-normal-range-lab-values-flash-cards/ 52.  A charge nurse is assessing staff knowledge about safety procedures regarding needle stick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safety procedures? REPEAT a.     “prophylactic treatment should be initiated after a needlestick during preparation of an injection.” b.     “I should stop the bleeding as soon as possible following a needlestick injury.” c.     “an incident report should be completed if a client receives a stick from her own used needle.” d.     “the needle should be recapped to prevent injury during transport to the biohazard container.” 53.  A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? a.     Obtaining a urine specimen from an older adult client (AP/CNA) b.     Providing postmortem care for a client who has just died (AP/CNA) c.     Accompanying a client who just had a wound debridement to physical therapy (AP/CNA) d.     Reinforcing dietary teaching with a client who has heart disease 54.  A nurse enters the room of a client who is unconscious and finds that the client’s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first? REPEAT a.     Recommend the son meet with the provider to get information about his mother’s condition b.     Complete an incident report regarding the breach of the client’s confidentiality c.     Log out the computer so that the client’s son is unable to view his mother’s information d.     Report the possible violation of client confidentiality to the nurse manager 55.  A home health nurse is assessing the home environment of a client who is on continuous oxygen therapy. Which of the following findings requires the nurse to intervene? a.     The oxygen machine has a grounded plug b.     The family keeps a spare oxygen tank in the room c.     The windows of the client’s room are open d.     The client is covered with a woolen blanket 56.  A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include? REPEAT a.     Elevate the arm for 1 min before taking the blood sample b.     Cap the lancet prior to putting it in the trash c.     Obtain the blood sample from the finger pads d.     Warm the hands prior to piercing the skin 57.  A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? REPEAT a.     Contact the client’s next of kin to obtain consent for treatment b.     Proceed with treatment without obtaining written consent c.     Have the client sign a consent for treatment d.     Notify risk management before initiating treatment 58.  A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include? REPEAT a.     The client should avoid using a microwave oven to heat food b.     Regular programming evaluations can be conducted by telephone c.     the client should avoid using remote control devices to prevent dysrhythmias   d.     Swimming could cause the unit to have an electrical short 59.  While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take? REPEAT a.     Reinforce the potential consequences of not having this information on record to the nursing staff b.     Ask nurses who are caring for clients without this information in the medical record to obtain it. c.     Meet with the nursing staff to review the policy regarding advance directives d.     Remind nurses to obtain this information during the admission process 60.  A client is admitted with COPD. Which of the following findings should the nurse report to the provider? REPEAT a.     Oxygen saturation 89% on room air b.     White blood cell count 9,000/mm^3 c.     Report of dyspnea on exertion d.     Bilateral crackles on auscultation of lungs 61.  A charge nurse notices that two staff nurses are not taking meal breaks during their regular 8-hr shifts. Which of the following actions should the nurse take first? a.     Providing coverage for the nurses’ breaks b.     Determining the reasons the nurses are not taking scheduled breaks c.     Discussing time management strategies with the nurses   d.     Review facility policies for taking scheduled breaks 62.  A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client’s care? (select all that apply.) REPEAT a.     Occupational therapist b.     Nutritional therapist c.     Physical therapist d.     Mental health counselor e.     Case manager 63.  A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective? REPEAT a.     “Guardian consent is required for an emancipated minor.” b.     “Consent can be given by a durable power of attorney.” c.     “A family member can interpret to obtain informed consent from a client who is deaf.” d.     “The nurse can answer any questions the client has about the procedure” 64.  A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? REPEAT a.     A client who is newly diagnosed with pancreatic cancer and scheduled to begin IV chemotherapy b.     A client who has peripheral vascular disease and has an absent pedal pulse in the right foot c.     A client who is postoperative following a laminectomy 12 hours ago and is unable to void   d.     A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38 C (101 F) 65.  A client is scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical units. Which of the following nursing statements is an appropriate nursing response? a.     “It’s not too late to cancel the surgery if you want to.” REPEAT b.     “This won’t take long and it will be over before you know it.”   c.     “Why did you make the decision to have this procedure?” d.     “You shouldn’t be worried because the procedure is very safe” 66.  A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority? a.     A client who has a raised red skin rash on his arms, neck, and face b.     A client who reports right-sided flank pain and is diaphoretic c.     A client who reports shortness of breath and left neck and shoulder pain d.     A client who has active bleeding from a puncture wound of the left groin area 67.  A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? REPEAT a.     Review current literature regarding client falls b.     Implement a fall prevention plan c.     Notify staff of the increased fall rate   d.     Identify clients who are at risk for falls 68.  A nurse is evaluating a newly licensed nurse who is administering a vitamin K. (Aquamephyton) injection to a newborn. Which of the following actions by the newly licensed nurse indicates understanding of the teaching? (Select all that apply.) REPEAT a.     Selects the dorsogluteal site to administer the injections b.     Cleans the injection site with alcohol c.     Applies gentle pressure at the site after injection d.     Aspirates the syringe for blood return after needle insertion e) Inserts the needle at a 45 degree angle (90 degree) 69.  A nurse enters a client’s room and observes a fire in the trash can. Identify the sequence of actions the nurse should take. (Move all the actions into the box on the right, placing them in the selected order of performance.) REPEAT Activate the fire alarm system 2 Confine the fire by closing doors and windows 3 Extinguish the fire if possible 4 Remove the client from the area 1 70.  Which of the following actions taken by a nurse constitutes battery? a.     Failing to put up side rails on a confused client’s bed b.     Telling a client who refused his oral medication that he will be given an injection c.     Inserting a feeding tube against the wishes of a client who refuses to eat (REPEAT) d.     Threatening to apply wrist restraints to control a client who is agitated