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ATI_Leadership_RN_2019
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ATI Leadership RN 20191. 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 refuse s 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
Answer: b-Document the client's refusal in the chart.
If the client is repeatedly refusing to provide specimen for drug test then nurse can just
documented his refusal. That document can be used against the client regarding the motor
vehicle accident.
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
Answer: b. Administer a nasogastric tube feeding
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 b. Opens the sterile pack by first
unfolding the top flap away from her body
Answer: d. Removes the outside packaging of a sterile instrument before dropping it onto the
sterile field
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.
Answer: a. Auscultate the client's lungs.
,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
Answer: a. Reinforcing teaching with a client who is learning to self-administer insulin
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.
Answer: c. The nurse holds her hands above her waist
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.
Answer: b. Recheck vital signs that are outside the expected reference range.
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
Answer: a. Obtaining a stool sample from a client who has renal failure
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)
Answer: b. A client who has two open chest wounds with a left tracheal deviation
, 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."
Answer: b. "Consent can be given by a durable power of attorney."
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
Answer: d. An adolescent client whose parents refuse a blood transfusion for religious reasons
12. 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
telehealth?
a. Assessing client needs
b. Developing client treatment protocols
c. Providing medication reconciliation
d. Establishing communication between providers (Community Health pg. 75)
Answer: 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)
Answer: a. Refer the client to the social services department.
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.
Answer: d. The emergency department nurse is waiting to give report on a new admission.
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