ATI LEADERSHIP PROCTORED -LATEST REVISION GUIDE QUESTIONS,ANSWERS AND RATIONALES 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
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ATI LEADERSHIP PROCTORED -LATEST REVISION GUIDE QUESTIONS,ANSWERS AND RATIONALES 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 (damaged capillaries) 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 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? 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 (select all that apply) - 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 vinyl flooring in the kitchen - 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 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 his a fever. b. A client whose pressure ulcer has serosanguineous drainage on the dressing-normal 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 to 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 post-operative 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? 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? 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 postterm 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 assignments. 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 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? 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 for falls 23. A nurse is completing a 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 a protective environment. d. The AP wears a mask when caring for a client who has varicella 24. A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse? a. Asses the staff nurses’ 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? 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? a. The client has used tacks to secure the carpet on the stairs X b. The client’s electrical cord is taped to the floor X c. The client's bedside lamp is plugged in using an extension cord with two prongs d. The client stores cleaning supplies in a locked cabinet above his head X 28. 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? A. Applies a mask before entering the client’s room B. Removes fresh flowers from the client’s room. C. Washes her hands with an alcohol-based hand rub after caring for the client. D. Wears a gown when caring for the client 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 supplies to manage tracheostomy at home? (Select all that apply.) A. Pipe cleaners B. O2 Tank C. Cotton balls D. Petroleum Jelly E. Obturator 30. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent? A. An adult client who has alcohol intoxication B. An adolescent client who is legally emancipated C. An older adult client who has questions about the procedure D. An adult client who has moderate Alzheimer’s disease. 31. 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? a. “I can wear my ankle bracelet since i am just having a local anesthetic: b. “I can leave my wedding ring on if it is taped in place” c. “I should remove my dentures before the procedure” d. “I should leave my valuables with a family member” 32. 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? a. Request the consultation after several wound care treatments are tried b. Arrange for the wound care nurse specialist to see the client daily to provide the recommended treatments c. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation d. Provide the consultant with subjective opinions and beliefs about the client’s wound care 33. 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? a. Positions the client on her left side with knees flexed b. Administers the solution at room temp c. Points tubing in the direction of the umbilicus during insertion d. Inserts the tubing 8cm (3.1 in) into the rectum 34. 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? a. “I should encrypt personal health information when sending emails.” b. “I can post the client’s vital signs in the client’s room.” c. “I can use another nurse’s password as long as i log off after using the computer” d. “I should discard personal health information documents in the trash before leaving the unit” 35. 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? a. ANA Standards of Practice b. ANA Code of Ethics c. State nurse practice act - showed up on practice tests d. Institute of medicine 36. 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? a. Veracity b. Justice c. Fidelity d. Nonmaleficence 37. A nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take? a. Use root cause analysis to identify gaps in meeting standards b. Establish work initiatives to promote a positive environment c. Compare practices within the facility against other high-performing facilities d. Determine how current practice will affect future performance within the facility 38. 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. Place a faulty equipment tag on the pump b. Notify the provider c. Auscultate the client’s lungs d. Complete an incident report 39. 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? a. “It’s not too late to cancel the surgery if you want to” b. “Why did you make the decision to have this procedure?” c. “This won’t take long and it will be over before you know it” d. “You shouldn’t be worried because the procedure is very safe” 40. 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? a. Lyme disease b. Bacterial conjunctivitis c. Health care-acquired pneumonia d. Methicillin-resistant Staphylococcus aureus 41. 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? 42. A nurse receives a new prescription over the telephone from a client’s provider. Which of the following actions should the nurse take first a. Write down the complete prescription b. Read back the prescription to the provider c. Document the prescription as a telephone prescription in the medical record d. Ensure that the provider signs the prescription 43. 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? a. Discuss the issue with the AP b. Notify the unit manager about the incident c. Reinforce facility protocols at the next staff meeting d. Alert the infection control department 44. 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? 45. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take? 46. 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? 47. 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? 48. 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? a. Libel b. Negligence c. Battery d. Slander 49. 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. A client who had a bladder scan that indicated 250 mL of urine in the bladder normal capacity between 400-600. b. A client who is 3 days postoperative and who’s dressing has serosanguinous drainage c. A client who has diabetes and an early morning blood glucose of 220 mg/dL d. A client who has a nasogastric tube to intermittent suction and reports nausea 50. 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? a. “Please stop discussing the client in a public area” b. “Do you understand the HIPPA regulations?” c. “We should discuss your concerns with the client’s care team” d. “I will notify the client’s provider about this breach of confidentiality 51. 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? A. Places sterile gauze 1.3cm (0.5 in) away from the edge of a sterile drape B. Uses sterile forceps to pack sterile gauze into the wound C. Sets up the sterile field 30min prior to performing the dressing change D. Uses a sterile-gloved hand to adjust the back of the sterile gown. 52. 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? CONTINUED........................DOWNLOAD FOR MORE REVIEW AND REVISION TO BEST SCORES
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