ATI LEADERSHIP PROCTORED 2019 REVISION GUIDE

ATI RN LEADERSHIP PROCTORED EXAM 2019 LATEST STUDY GUIDE BEST FOR MAIN EXAM AND RETAKE REVISION GUIDE 1. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash ...

ATI RN LEADERSHIP PROCTORED EXAM 2019 LATEST STUDY GUIDE BEST FOR MAIN EXAM AND RETAKE REVISION GUIDE 1. 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? a. Tell the client that a catheter will be inserted. b. Document the client’s refusal in the chart. c. Assess the client for urinary retention. d. Obtain a provider’s prescription for a blood alcohol level. 2. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? a. Pick up the meal trays after lunch. b. Administer a nasogastric tube feeding. c. Plan break times for assistive personnel. d. Determine adequacy of ventilator settings. 3. 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) a. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field b. Opens the sterile pack by first unfolding the top flap away from her body c. Prepares a container of sterile solution on the field after putting on sterile gloves d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field e. Holds the sterile solution bottle with the label facing up 4. A nurse enters a client’s room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first? a. Auscultate the client’s lungs. b. Notify the provider. c. Place a faulty equipment tag on the pump. d. Complete an incident report. 5. 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? a. Reinforcing teaching with a client who is learning to self-administer insulin b. Ambulating a client who is scheduled for discharge later in the day c. Administering morphine IV bolus to a client who is hr postoperative d. Admitting a new client who has chronic back pain to the unit 6. 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? a. The nurse applies goggles. b. The nurse turns her back to the sterile field. c. The nurse holds her hands above her waist. d. The nurse puts on a face mask. 7. 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? a. Review vital sign trends at the end of the shift. b. Recheck vital signs that are outside the expected reference range. c. Ask the AP to write a summary of the delegated tasks during the shift. d. Compare the vital signs the AP obtained with those taken by another AP on a previous shift. 8. A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel? a. Obtaining a stool sample from a client who has renal failure b. Monitoring a client who has a fluid restriction c. Assessing a client who just returned from hemodialysis d. Reviewing dietary instructions for a client who has kidney stones 9. A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first? a. A client who has a neck injury and is unable to breathe spontaneously b. A client who has two open chest wounds with a left tracheal deviation c. A client who has major burns over 75% of her body surface area d. A client who has bipolar disorder and is exhibiting signs of hallucination (Class 3) 10. 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. “A family member can interpret to obtain informed consent from a client who is deaf.” b. “Consent can be given by a durable power of attorney.” c. “Guardian consent is required for an emancipated minor.” d. “The nurse can answer any questions the client has about the procedure.” 11. A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee? a. A middle adult client who leaves the facility against medical advice b. An older adult client who has advanced directives on file c. A young adult client who is participating in a medical research study d. An adolescent client whose parents refuse a blood transfusion for religious reasons 12. 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? a. Assessing client needs b. Developing client treatment protocols c. Providing medication reconciliation d. Establishing communication between providers (Community Health pg. 75) 13. 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? a. Refer the client to the social services department. b. Provide the client with a week’s worth of supplies from the hospital (still needs help paying after) c. Ask the provider about the possibility of less frequent monitoring (pt needs to monitor often) d. Recommend the client reuse the testing lancets (breaks the safety & infection protocol) 14. A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first? a. A nurse on the previous shift wrote an incident report about a medication error. b. Two staff members have called to say they will be absent. c. Transport assistance is unavailable to take a client to occupational therapy. d. The emergency department nurse is waiting to give report on a new admission. 15. 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. Complete required tasks. b. Review the client’s new laboratory values. c. Determine client care goals (set/plan goals) d. Document assessment data. 16. 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? a. “Clients who participate in research studies forfeit their HIPAA right to privacy.” b. “HIPAA allows facility-specific coding of client health care information to ensure privacy.” c. “HIPAA prohibits the uploading of photographs of client’s providers to social media sites.” d. “HIPAA allows clients to request a review of their own medical records.” 17. 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? a. Whether the client understands the risk of refusing the procedure b. Whether the facility ethics committee reached a consensus on the case c. Whether the partner is the client’s durable power of attorney for health care d. Whether the client’s refusal is based on religious belief 18. 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? a. Conduct the newborn hearing screening. (RN assessment) b. Administer a hepatitis B vaccine. c. Perform a New Ballard screening. (RN assessment) d. Obtain vital signs. (CNA) 19. 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? a. Train LPNs to reinforce teaching with clients using a standardized teaching plan. b. Determine factors that interfere with the documentation of client education. c. Include documentation of client education as part of unit nurses’ annual performance evaluation. d. Offer incentives for the staff once the unit’s results are back in adherence with the benchmark. 20. 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? a. Utility b. Autonomy c. Nonmaleficence d. Veracity 21. A nurse is caring for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past 24 hr (improvement) b. A client who has diabetes mellitus and reports paresthesia in his fingers and toes (ABC-- circulation) c. A client who has a nasogastric tube and has crackles in the lungs (ABC--airway) d. A client who has a new diagnosis of Graves’ disease and a TSH level of 0.2 microunits/mL 22. 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. A client who is in Buck’s traction for a left hip fracture (can’t necessarily move too much) b. A client who is 1 day postoperative following thoracic surgery and has a chest tube (possible physical instability) c. A client who is confused and restrained for safety (still needs continual nursing care/assessment) d. A client who is receiving IV chemotherapy and is ambulatory 23. 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? a. Recommend the son meet with the provider to get information about his mother’s condition. b. Report the possible violation of client confidentiality to the nurse manager. c. Complete an incident report regarding the breach of the client’s confidentiality. d. Log out the computer so that the client’s son is unable to view his mother’s information. 24. 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? a. Explain the risks of the procedure to the client. b. Convey the client’s request to the nurse who witnessed the consent. c. Check to see if the medial record indicates the provider explained the procedure to the client. d. Notify the provider about the client’s concerns. 25. A nurse is prioritizing care after receiving change-of-shift report on four clients. Which of the following clients should the nurse assess first? a. A client who reports a headache with sensitivity to light b. A client who reports an urge to void but has not urinated during the prior shift c. A client who reports indigestion and pain in her jaw d. A client who reports feeling lightheaded when he stands up from a lying position 26. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? a. Discuss time management strategies with the nurses. b. Determine the reasons the nurses are not taking scheduled breaks. Assess first c. Provide coverage for the nurses’ breaks. d. Review facility policies for taking scheduled breaks. 27. 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? a. 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) b. Is the client’s family present so the AP can show them how to turn the client? (this is not necessary) c. 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) d. Does the AP have the time to change the client’s central IV line dressing after turning her? (AP cannot change dressings) 28. 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. A prescribed consultation -under situation b. The client’s vital signs c. The client’s name -under situation d. The client’s code status -under situation 29. 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? a. “I need some help planning my meals to maintain my weight.” b. “I am tired of having pain in my joints all the time.” c. “I’m having difficulty climbing the stairs at my house.” d. “I will need assistance with bathing.” 30. 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? a. Ask the adult neighbor to sign the consent form. b. Obtain consent from the hospital administrator. c. Witness the client signing the consent form. d. Attempt to notify the client’s guardian to obtain consent. 31. A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority? a. A client who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds b. A client who has COPD and has an oxygen saturation of 90% c. A client who had a cholecystectomy 6 hr ago and is requesting pain medication d. A client whose TPN was discontinued 4 hr ago and is requesting clear liquids 32. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following actions should the charge nurse take? a. Assign clients who are not prescribed narcotics to the staff nurse. b. Collect data about the staff nurse to support further action. c. Report the staff nurse to the facility ethics committee. d. Counsel the staff nurse about substance use. 33. 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? a. “I will be given contrast dye during this test.” b. “I might have to wear a nose clip during this test.” c. “I might have a tube inserted into my airway during the test.’ d. “I will run on a treadmill during this test.” 34. A nurse in the emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first? a. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood b. An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10 c. An older adult client who has dyspnea and a respiratory rate of 26/min d. An adult client who has large ecchymosis on both legs 35. 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? a. Collaborating b. Smoothing c. Accommodating d. Compromising 36. A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to an assistive personnel? a. Advising a client on self-administration of acetaminophen b. Informing a family of a client’s progress in physical therapy c. Teaching a client to perform a finger-stick for testing blood glucose levels d. Performing post mortem care prior to transferring the client to the morgue 37. A nurse is providing discharge teaching to a client following a total knee arthroplasty. Which of the following information should the nurse include (SATA) a. Advance directives information b. Contact information for the physical therapist c. Medication guidelines information d. Insurance information e. Information about follow-up care 38. 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? a. “This service offers psychological interventions during and after your wife’s illness.” b. “The clinicians help reduce the severity of your wife’s physical problems.” c. “This service delivers meals and supplies to reduce your errands away from home.” d. “It makes it possible for you to have some time away from caring for your wife.” 39. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include? a. Warm the hands prior to piercing the skin. b. Cap the lancet prior to putting it in the trash.- never recap c. Elevate the arm for 1 min before taking the blood sample.- has to be down so gravity can assist to milk the blood out . d. Obtain the blood sample from the finger pads. 40. 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? a. Receptive aphasia→ unable to understand language in its written or spoken form b. Facial drooping→ speech therapist c. Memory loss d. 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. 41. 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. A network for communication between staff members and families b. A mental health specialist on the response team c. A sufficient supply of personal protective equipment d. A system for tracking client information 42. 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? a. Rotavirus b. Pertussis c. Respiratory syncytial virus d. Group B streptococcal disease 43. 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? a. Chlorine bleach b. Triclosan c. Chlorhexidine d. Isopropyl alcohol 44. 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? a. Treat and discharge the client. b. Ask the client’s son to go to the waiting area. c. File an incident report. d. Ask the client about his injuries with the son present 45. 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? a. “I need to take my prescribed medication for 3 months.” b. “I should have a sputum culture done every 2 to 4 weeks.” c. “I need to have a TB skin test done once per year.” d. “I should wear a mask while around my family.” 46. 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? a. Checking the pulses of the client’s right foot b. Recording the client’s vital signs c. Turning the client d. Determining the client’s pain level 47. 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? a. Inspect the skin of a newborn who is receiving phototherapy. – Assess b. Answer the parents’ questions about newborn circumcision. - Teaching c. Show a new mother how to change the newborn’s diaper. - Teaching d. Obtain the weight of a newborn that is receiving formula 48. 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. “A provider can write a prescription for restraints ‘as needed’.” b. “I need to tie the restraint to the part of the bed frame that moves.” c. “I should tie the restraints using a square knot.” d. “I will remove a client’s restraints every 4 hours.” 49. 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? a. Mumps b. Rubeola c. Varicella d. Rotavirus 50. 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? a. “Hospice care will prolong the life expectancy of clients who are terminally ill.” b. “Hospice care is a multidisciplinary program for clients who are terminally ill.” c. “Hospice care is helpful for clients at various stages of chronic illness.” d. “Hospital access is no longer available for clients who are in hospice care.” 51. 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? a. Decide how often to measure vital signs. b. Explain to the client about a 24-hr urine specimen collection. c. Determine the client’s muscle strength prior to ambulation. d. Remind the client to change positions slowly. 52. 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? a. Notify the risk management department of the situation. (4) b. Review with the nurse the principles of medication administration. (2) c. Ask the nurse to describe her medication administration procedure. (1) d. Identify education opportunities for the nurse regarding safe medication administration. (3) 53. 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 a. Libel : talking bad about someone via writing it in notes b. Battery : intentional/wrongful physical contact c. Slander : Defamation with the spoken word d. Negligence 54. 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? a. Place the client’s ring in the facility safe. b. Tape the ring securely to the client’s finger. c. Place the ring in the bad with the client’s clothing. d. Agree to keep the ring for the client until after surgery. 55. A nurse is prioritizing postpartum care for four clients. Which of the following actions should the nurse take first? a. Assist a client who requests help breastfeeding her 4-hr-old newborn. b. Administer RH immune globulin to a client who is Rh-negative and 6 hr postpartum. c. Check uterine tone for a client who received methylergonovine- if the uterine tone is not d. Instruct a client who has an episiotomy about a sitz bath. 56. 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? a. Withhold the benzodiazepine but continue the opioid. b. Contact the provider about replacing the opioid with an NSAID. c. Administer the benzodiazepine but withhold the opioid. d. Continue the medication dosages that relieve the client’s pain. 57. 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? a. Administers the solution at room temperature b. Points tubing in the direction of the umbilicus during insertion c. Position the client on her left side with knees flexed d. Inserts the tubing 8 cm (3.1 in) into the rectum 58. 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 a. Instructions regarding treatments the client desires or does not desire – (livings wills and durable power of attorney make up AD). b. Information regarding the disposition of the client’s body upon death c. Information regarding organ donation d. A form with directions for contacting next of kin 59. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? a. A client who has peripheral vascular disease ad has an absent pedal pulse in the right foot b. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy. c. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38C (101F) d. A client who is postoperative following a laminectomy 12 hr ago and is unable to void 60. 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? a. “In the role of client advocate, I should take responsibility for coordinating each client’s care.” b. “As a client advocate, I will suggest the best course of action for clients who are indecisive.” c. “My role as a client advocate is to empower the clients to make informed healthcare decisions.” d. “As a client advocate, I will adhere to the provider’s prescribed treatments.” 61. 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? a. Refer the AP to the facility procedure manual. b. Instruct the AP to request assistance when unsure about a task. c. Help the AP assist the client with the transfer. d. Demonstrate the proper client transfer technique for the AP. 62. 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? a. Chlamydia trachomatis b. Pediculosis capitis c. Impetigo contagiosa d. Candida albicans 63. 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? a. Escort the nurses to the nurses’ lounge to continue the discussion. b. Recommend that both nurses be terminated. c. Make arrangements to take over the client’s care. d. Contact the house supervisor to mediate the conflict. 64. 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? a. Accept the assignment with help from assistive personnel on the unit. b. Request that the charge nurse modify the assignment. c. Document the concern in the nurse’s notes. d. Notify the risk manager. 65. 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? a. Recommending a referral for a client who requires physical therapy b. Suggesting a client’s partner attend a support group for emotional support c. Evaluating a client’s home for safety hazards d. Completing an incident report following a medication error 66. 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? a. Administer IV nitroglycerin to a client who is experiencing chest pain. b. Perform a urinary catheterization for a client who has experienced a cerebrovascular accident. c. Set up a trauma room for an incoming client who was in a motor-vehicle crash. d. Complete a SAD PERSONS assessment scale for a client who has attempted suicide. 67. 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. A folding chair without arm rests b. A wheeled office chair at the client’s computer desk c. A throw rug covering some cracked vinyl flooring in the kitchen d. A two-wheeled walker used to assist the client with ambulation e. A raised vinyl seat on the toilet in the bathroom 68. A nurse in a long-term care facility should identify that which of the following will provide security for clients who have dementia? a. Turning off room lights at night b. Using a facility c. Restricting space to reduce pacing d. Setting alarms on exits 69. 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? a. Have the client sign a consent for treatment b. Notify risk management before initiating treatment c. Proceed with treatment without obtaining written consent (Implied Consent) d. Contact the client’s next of kin to obtain consent for treatment 70. 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? a. Inform the nursing supervisor. b. Notify the provider c. Observe the client’s condition. d. Complete an incident report. 1. 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. a. Erythema on the skin surrounding a client's wound b. Deep red color on the center of the clients wound c. Inflammation noted on the tissue edges of a client's wound d. Increase in serosanguineous exudate from the clients wound 2. A nurse received change of shift report at 0700 for four clients. Which of the following actions should the nurse perform first? a. Obtain a breakfast tray for a client who received a morning dose of insulin aspart b. Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400 c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900 d. 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) 3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse? a. A client who has multiple sclerosis and ataxia b. A client who has brain tumor and is admitted for chemotherapy c. A client who has guillain-barre syndrome and a tracheostomy d. A client who sustained a concussion and is being monitored for complication 4. A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? a. “Once I sign my living will, a family member must co sign it” b. “I will wait until I have a serious health problems to sign my advance directives” c. “My doctor will need to provide approval for the decisions outlines in my living will d. “My durable power of attorney for health care is part of my advance directives” 5. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first? a. Identify the industry standards for infant safety b. Evaluate the selected infant safety system c. Choose an infant safety system d. Establish measurement criteria for infant safety systems 6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform dysphagia screening to determine the client's need for a referral to which of the following providers? a. Physical therapist b. Respiratory therapist c. Speech therapist d. Occupational therapist 7. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls (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 8. A nurse manager is planning to assign care for four clients on a medical surgical unit. Which of the following clients should the nurse assign to a LPN a. An older adult who has lung cancer and has periodic episodes of severe dyspnea b. A middle adult client who has a below the knee amputation and requires a dressing change c. A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus d. An adolescent who requires teaching regarding insulin administration 9. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority for the nurse to take? a. Remind nurses to obtain this information during the admission process b. Reinforce the potential consequences of not having his information on record to the nursing staff c. Meet with nursing staff to review the policy regarding advance directive d. Ask nurse who are caring for client without his information in the medical record to obtain it 10. A nurse is caring for a group of clients. Which of the following should the nurse see first? a. A client who is postoperative and has a fever. b. A client whose pressure ulcer has serosanguineous drainage on the dressing c. A client who has diabetes mellitus and is diaphoretic d. A client who has a fractured hip and reports a pain level of 7 on a scale from 0-10 11. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse care for first? a. A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg b. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea c. A client who has pneumonia and requires a tracheostomy dressing change d. A client who has a new colostomy and requires discharge teaching 12. 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? a. Acknowledge the conflict and encourage the nurses to focus on working as a team b. Gather information regarding the situation c. Encourage the nurses to resolve the conflict autonomously d. Meet with a committee from each shift to discuss issues related to the conflict 13. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first? a. Don personal protective equipment b. Irrigate the exposed area with water c. Remove the client’s clothing d. Report the incident to OSHA 14. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first? a. Complete an incident report b. Measure the client’s vital signs c. Inform the nurse manager d. Call the provider 15. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately? a. Decreased level of consciousness b. Generalized rash over trunk c. Increased temperature d. Report of photophobia 16. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway? a. 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. An allergy to penicillin required an alternative antibiotic to be prescribed d. The route of antibiotic therapy on the care pathway was changed from IV to PO 17. A nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager assign to a float nurse from the medical-surgical unit? a. A client who is post term and is receiving oxytocin for labor induction b. A client who gave birth to her first child and requires instruction on breastfeeding techniques c. A client who is 2 days post-operative following a caesarean birth and is having difficulty ambulating d. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion 18. 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? a. Risk management coordinator b. Clinical pharmacist c. Nursing supervisor d. Infection control nurse 19. A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take? a. Discuss with the client her concerns regarding the procedure b. Provide the client with information on treatment options and outcomes c. Inform the client of the consequences of uterine prolapse and the need for intervention d. Initiate a mental health consult to determine the client’s reasons for refusing surgery 20. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? a. Delay the surgery until the nurse can obtain informed consent b. Obtain telephone consent from the facility administrator before the surgery. c. Ask the anesthesiologist to sign the consent. d. Transport the client to the operating room without verifying informed consent. 21. A nurse is planning to delegate client care assignment. Which of the following tasks should the nurse plan to delegate to an assistive personnel? a. Performing postmortem care prior to transferring the client to the morgue b. Advising a client on self-administration of acetaminophen c. Teaching a client to perform a finger-stick for testing blood glucose levels d. Informing a family of a client’s progress in physical therapy 22. 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? a. Notify staff of the increased fall rate b. Review current literature regarding client falls c. Implement a fall prevention plan d. Identify clients who are at risk of falls 23. A nurse is completing performance evaluation for an assistive personnel (AP). Which of the following actions by the AP requires intervention by the nurse? a. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile. b. The AP closes the door of a client who is on airborne precautions. c. The AP Removes cut flowers from the room of a client who is in protective environment. d. The AP wears a mask when a caring for a client who has varicella. 24. 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? a. Assess the staff nurse’s knowledge deficit. b. Pair an inexperienced nurse with an experienced nurse. c. Demonstrate use of the pump during medication administration. d. Plan an in-service education program on the unit. 25. 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? a. Administer the initial bolus feeding to a client who has NG tube b. Check a client pain level 30min after receiving acetaminophen c. Collect urine specimen for newly admitted client d. Instruct a client to splint an abdominal incisions 26. A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a client. Which of the following actions should the nurse take? a. Treat the client’s injuries within 30 min b. Provide treatment for life-threatening injuries c. Provide treatment for minor injuries d. Allow the client to die without further intervention 27. A home health nurse is performing a safety assessment of a client’s home. Which of the following findings should the nurse identify as a safety hazard? CONTINUED.......................DOWNLOAD FOR BEST REVISION GUIDE