Nurse observes AP incorrectly transfer client. Which of the following actions should the nurse take first?

Refer the AP to the facility procedure manual

The client and her partner are asking the nurse about hospice care. Which of the statements by the nurse is appropriate?

Hospice care is multidisciplinary program for clients who are terminally il

Which of the following is an appropriate procedure for taking care of aclient's ring?

Place the client's ring in the facility safe

A nurse is prioritizing postpartum care for four clients. Which of the following actions should the nurse take first?

Check uterine tone for a client who received methylergonovine

Which of the following statements by a staff nurse indicates understanding?

HIPAA allows clients to request a review of their own medical records

Which of the following clients should the nurse assess first?

A client who reports indigestion and pain in her jaw

Which of the following findings should the nurse identify as increasing the client's risk for falls?

A wheeled office chair at the client's computer desk, A folding chair without arm rests, A throw rug covering some cracked vinyl flooring in the kitchen

Which of the following statements by a staff nurse indicates that the teaching about informed consent was effective?

Consent can be given by a durable power of attorney

A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority?

Client who had cardiac catheterization capillary refill in great toe is 4s

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

Administer a nasogastric tube feeding

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 a nasogastric tube and has crackles in the lungs

Which of the following assessments should the nurse make before delegating care?

Has data been collected about specific client needs related to turning?

Results for documenting client education are low. Which of the following strategies should nurse manager implement first

Determine factors that interfere with the documentation of client education

The client expresses concern about the cost of blood-glucose monitoring supplies. Which of the following actions?

Refer the client to the social services department

Nurse observes AP administer enema. For which of the following actions by the AP should the nurse intervene?

Position the client on her left side with knees flexed

Which of the following should nurse identify as an indication that a referral to an occupation therapist is necessary?

I will need assistance with bathing

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

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

Establishing communication between providers

Nurse administers opioid+benzodiazepine, client becomes somnolent and difficult to arouse. What action should nurse take

Contact the provider about replacing the opioid with an NSAID

Which of the following is an appropriate task for the AP?

Obtain the weight of a newborn that is receiving formula

Just before procedure, client asks nurse about risks of procedure. Which of the following actions should the nurse take?

Notify the provider about the client's concerns

Which of the following clients should the nurse recommend to be examined first?

An older adult client who has dyspnea and a respiratory rate of 26/min

Which of the following client statements indicates to the nurse an understanding of the pulmonary function test?

I might have to wear a nose clip during this test

Which of the following statements by the client indicates an understanding of the teaching anout TB?

I should have a sputum culture done every 2 to 4 weeks

Charge nurse discovers staff nurse has made repeated medication errors. Which of the following actions should take 1st

Ask the nurse to describe her medication administration procedure

A nurse is planning care for a client who has Addison's disease. Which of the tasks should nurse plan to delegate to AP

Remind the client to change positions slowly

When client's partner asks how respite service can help, which of the following responses by the nurse is appropriate?

It makes it possible for you to have time away from caring for your wife

Information for discharge teaching about total knee athroplasty should include

Contact information for the physical therapist, Information about follow-up care

Client is unconscious and finds son reading EMR from bedside. Which of the following actions should the nurse take first

Logout computer so the client's son cannot view his mother's information

After donning sterile gown&gloves, which of the actions by newly licensed nurse demonstrates correct aseptic technique?

The nurse holds her hands above her waist

Client refuses to provide urine specimen after suspected drug use in a motor-vehicle crash. Appropriate action?

Document the client's refusal in the chart

Which of the following statements indicates an understanding of the teaching about restraints?

I will remove a client's restraints every 4 hours

Which of the following tasks should the nurse assign to the LPN?

Reinforcing teaching w a client who is learning to selfadminister insulin

Which of the following statements by a nurse indicates an understanding of the role of a client advocate?

Empower the clients to make informed healthcare decisions

Which of the following resources is the highest priority to have available in response to a bioterrorism event?

A sufficient supply of personal protective equipment

16 y/o has ruptured appendix and requires emergency sx. Accompanied by adult neightbor. What actions should nurse take?

Attempt to notify the client's guardian to obtain consent

Which of the following actions indicates the newly licensed nurse is maintaining sterile technique?

Opens the sterile pack by first unfolding the top flap away from her body, Removes outside packaging instrument before dropping it on sterile field

The client arrives to ED disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

Proceed with treatment without obtaining written consent

ER charge is supervising nurse floating from med/surg. Which of the following assignments is appropriate for the float?

Perform a urinary catheterization for a client who has experienced CVA

Which of the following can be delegated to an assistive personnel for an elderly pt waiting surgery for fractures hip?

Recording the client's vital signs

Two staff nurses do not take meal breaks. Which of the following actions should the nurse take first?

Determine the reasons the nurses are not taking scheduled breaks

For which of the following clients should the nurse collaborate with the facility ethics committee?

An adolescent client whose parents refuse blood transfusion for religious

Which of the following tasks should the nurse plan to delegate to an assistive personnel?

Teaching a client to perform a fingerstick for testing blood glucose levels

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ATI nursing leadership

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Questions 70

Answers

1
Nurse observes AP incorrectly transfer client. Which of the following actions should the nurse take first?
Instruct the AP to request assistance when unsure about a task
Demonstrate the proper client transfer technique for the AP
Refer the AP to the facility procedure manual
Help the AP assist the client with the transfer
2
The client and her partner are asking the nurse about hospice care. Which of the statements by the nurse is appropriate?
Hospice care is multidisciplinary program for clients who are terminally il
Hospital access is no longer available for clients who are in hospice care
Hospice care prolongs the life expectancy of clients who are terminally ill
Hospice care is helpful for clients at various stages of chronic illness
3
Which of the following is an appropriate procedure for taking care of aclient's ring?
Place the client's ring in the facility safe
Agree to keep the ring for the client until after surgery
Tape the ring securely to the client's finger
Place the ring in the bad with the client's clothing
4
A nurse is prioritizing postpartum care for four clients. Which of the following actions should the nurse take first?
Check uterine tone for a client who received methylergonovine
Instruct a client who has an episiotomy about a sitz bath
Assist a client who requests help breastfeeding her 4-hr-old newborn
Administer RH immune globulin to a client who is Rhnegative+6 hr postpartum
5
Which of the following statements by a staff nurse indicates understanding?
HIPAA prohibits uploading photographs of clients providers to social media
HIPAA allows clients to request a review of their own medical records
Clients who participate in research studies forfeit HIPAA right to privacy
HIPAA allows facilityspecific coding of client health care info for privacy
6
Which of the following clients should the nurse assess first?
A client who reports indigestion and pain in her jaw
A client who reports an urge to void but has not urinated
A client who reports a headache with sensitivity to light
A client who reports feeling lightheaded when stands up from lying position
7
Which of the following findings should indicate the need for referral to an occupational therapist after stroke?
Unilateral neglect
Memory loss
Receptive aphasia
Facial drooping
8
Which of the following findings should the nurse identify as increasing the client's risk for falls?
A two-wheeled walker used to assist the client with ambulation
A wheeled office chair at the client's computer desk
A folding chair without arm rests
A throw rug covering some cracked vinyl flooring in the kitchen
9
Which of the following diseases should the nurse report to the state health department?
Pertussis
Rotavirus
Respiratory syncytial virus
Group B streptococcal disease
10
Which of the following statements by a staff nurse indicates that the teaching about informed consent was effective?
Guardian consent is required for an emancipated minor
A family member can interpret informed consent from a client who is deaf
The nurse can answer any questions the client has about the procedure
Consent can be given by a durable power of attorney
11
A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority?
A client whose TPN was discontinued 4 hr ago and is requesting clear liquid
Client who had cardiac catheterization capillary refill in great toe is 4s
A client who had a cholecystectomy 6 hr ago and is requesting pain med
A client who has COPD and has an oxygen saturation of 90%
12
Which of the following tasks is appropriate to assign to a licensed practical nurse?
Plan break times for assisstive personnel
Determine adequacy of ventilator settings
Pick up the meal trays after lunch
Administer a nasogastric tube feeding
13
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 a new diagnosis of Graves' and TSH level of 0.2 mu/mL
A client who has congestive heart failure and has lost 2 lb in the 24 hr
A client who has diabetes mellitus and reports paresthesia in fingers/toes
A client who has a nasogastric tube and has crackles in the lungs
14
Which of the following assessments should the nurse make before delegating care?
Has data been collected about specific client needs related to turning?
Is client's family present so the AP can show them how to turn the client?
Has the AP checked the client's pain level prior to turning her?
Does AP have time to change clients central IV line dressing after turning?
15
Client is receiving too much IV fluid because IV pump is not working. Which of the 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
16
Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions?
Varicella
Mumps
Rubeola
Rotavirus
17
Results for documenting client education are low. Which of the following strategies should nurse manager implement first
Train LPNs to reinforce teaching w clients using standardized teaching plan
Offer incentives for the staff once the unit's results are back
Include documentation of client education as part nurses annual performance
Determine factors that interfere with the documentation of client education
18
The client expresses concern about the cost of blood-glucose monitoring supplies. Which of the following actions?
Ask the provider about the possibility of less frequent monitoring
Refer the client to the social services department
Recommend the client reuse the testing lancets
Provide the client with a week's worth of supplies from the hospital
19
Nurse observes AP administer enema. For which of the following actions by the AP should the nurse intervene?
Position the client on her left side with knees flexed
Administers the solution at room temperature
Points tubing in the direction of the umbilicus during insertion
Inserts the tubing 8 cm (3.1 in) into the rectum
20
Which of the following should nurse identify as an indication that a referral to an occupation therapist is necessary?
I am tired of having pain in my joints all the time
I need some help planning my meals to maintain my weight
I will need assistance with bathing
I'm having difficulty climbing the stairs at my house
21
A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel?
Reviewing dietary instructions for a client who has kidney stones
Assessing a client who just returned from hemodialysis
Monitoring a client who has a fluid restriction
Obtaining a stool sample from a client who has renal failure
22
The nurse should explain that which of the following is an objective of telehealth?
Establishing communication between providers
Providing medication reconciliation
Developing client treatment protocols
Assessing client needs
23
Nurse administers opioid+benzodiazepine, client becomes somnolent and difficult to arouse. What action should nurse take
Continue the medication dosages that relieve the client's pain
Withhold the benzodiazepine but continue the opioid
Contact the provider about replacing the opioid with an NSAID
Administer the benzodiazepine but withhold the opioid
24
A nurse in a long-term care facility should identify that which 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
25
Which of the following is an appropriate task for the AP?
Obtain the weight of a newborn that is receiving formula
Answer the parents' questions about newborn circumcision
Inspect the skin of a newborn who is receiving phototherapy
Show a new mother how to change the newborn's diaper
26
Just before procedure, client asks nurse about risks of procedure. Which of the following actions should the nurse take?
Check if medical record indicates provider explained procedure to client
Convey the client's request to the nurse who witnessed the consent
Notify the provider about the client's concerns
Explain the risks of the procedure to the client
27
Which of the following clients should the nurse recommend to be examined first?
An adult client who has large ecchymosis on both legs
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
An older adult client who has dyspnea and a respiratory rate of 26/min
28
Which of the following client statements indicates to the nurse an understanding of the pulmonary function 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 be given contrast dye during this test
I will run on a treadmill during this test
29
Which of the following statements by the client indicates an understanding of the teaching anout TB?
I should wear a mask while around my family
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 need to take my prescribed medication for 3 months
30
Charge nurse discovers staff nurse has made repeated medication errors. Which of the following actions should take 1st
Identify education opportunities for the nurse regarding safe medication
Ask the nurse to describe her medication administration procedure
Review with the nurse the principles of medication administration
Notify the risk management department of the situation.
31
A nurse is planning care for a client who has Addison's disease. Which of the tasks should nurse plan to delegate to AP
Determine the client's muscle strength prior to ambulation
Decide how often to measure vital signs
Remind the client to change positions slowly
Explain to the client about a 24-hr urine specimen collection
32
Which of the following infections should the nurse report to the state health department?
Impetigo contagiosa
Pediculosis capitis
Chlamydia trachomatis
Candida albicans
33
When client's partner asks how respite service can help, which of the following responses by the nurse is appropriate?
This service delivers meals and supplies to reduce errands away from home
It makes it possible for you to have time away from caring for your wife
Service offers psychological interventions during+after your wife's illness
The clinicians help reduce the severity of your wife's physical problems
34
Information for discharge teaching about total knee athroplasty should include
Contact information for the physical therapist
Medication guidelines information
Advance directives information
Information about follow-up care
35
Client is unconscious and finds son reading EMR from bedside. Which of the following actions should the nurse take first
Complete incident report regarding breach of the client's confidentiality
Report possible violation of client confidentiality to the nurse manager
Recommend son meet with provider to get info about his mother's condition
Logout computer so the client's son cannot view his mother's information
36
After donning sterile gown&gloves, which of the actions by newly licensed nurse demonstrates correct aseptic technique?
The nurse applies goggles
The nurse turns her back to the sterile field
The nurse puts on a face mask
The nurse holds her hands above her waist
37
Client refuses to provide urine specimen after suspected drug use in a motor-vehicle crash. Appropriate action?
Assess the client for urinary retention
Obtain a provider's prescription for a blood alcohol level
Document the client's refusal in the chart
Tell the client that a catheter will be inserted
38
The nurse should explain that preventing client injury by removing a fall hazard demonstrates which ethical principle?
Autonomy
Utility
Veracity
Nonmaleficence
39
Which of the following statements indicates an understanding of the teaching about restraints?
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
A provider can write a prescription for restraints 'as needed'
40
Which of the following tasks should the nurse assign to the LPN?
Ambulating a client who is scheduled for discharge later in the day
Reinforcing teaching w a client who is learning to selfadminister insulin
Administering morphine IV bolus to a client who is __ hr postoperative
Admitting a new client who has chronic back pain to the unit
41
Which of the following statements by a nurse indicates an understanding of the role of a client advocate?
I will adhere to the provider's prescribed treatments
I will suggest the best course of action for clients who are indecisive
I should take responsibility for coordinating clients care
Empower the clients to make informed healthcare decisions
42
Which of the following resources is the highest priority to have available in response to a bioterrorism event?
A mental health specialist on the response team
A network for communication between staff members and families
A system for tracking client information
A sufficient supply of personal protective equipment
43
16 y/o has ruptured appendix and requires emergency sx. Accompanied by adult neightbor. What actions should nurse take?
Witness the client signing the consent form
Ask the adult neighbor to sign the consent form
Attempt to notify the client's guardian to obtain consent
Obtain consent from the hospital administrator
44
Which of the following actions indicates the newly licensed nurse is maintaining sterile technique?
Opens the sterile pack by first unfolding the top flap away from her body
Prepares container of sterile solution onfield after putting sterile gloves
Removes outside packaging instrument before dropping it on sterile field
Places sterile items within 0.5 in) border around edges of sterile field
45
The client arrives to ED disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
Proceed with treatment without obtaining written consent
Have the client sign a consent for treatment
Notify risk management before initiating treatment
Contact the client's next of kin to obtain consent for treatment
46
ER charge is supervising nurse floating from med/surg. Which of the following assignments is appropriate for the float?
Complete a SADPERSONS assessment scale for client who has attempted suicide
Set up a trauma room for an incoming client who was in a motorvehicle crash
Perform a urinary catheterization for a client who has experienced CVA
Administer IV nitroglycerin to a client who is experiencing chest pain
47
Which of the following can be delegated to an assistive personnel for an elderly pt waiting surgery for fractures hip?
Checking the pulses of the client's right foot
Turning the client
Determining the client's pain level
Recording the client's vital signs
48
Two staff nurses do not take meal breaks. Which of the following actions should the nurse take first?
Review facility policies for taking scheduled breaks
Provide coverage for the nurses' breaks
Discuss time management strategies with the nurses
Determine the reasons the nurses are not taking scheduled breaks
49
Progress report falsey idenitifies client as HIV+ due to multiple sex partners. Nurse manager should identify
Battery
Libel
Slander
Negligence
50
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 adolescent client whose parents refuse blood transfusion for religious
A young adult client who is participating in a medical research study
An older adult client who has advanced directives on file
51
Which of the following tasks should the nurse plan to delegate to an assistive personnel?
Advising a client on self-administration of acetaminophen
Performing post mortem care prior to transferring the client to the morgue
Teaching a client to perform a fingerstick for testing blood glucose levels
Informing a family of a client's progress in physical therapy
52
Patient refuses surgery, partner wants surgery. Which is the deciding factor in determining if the surgery will be done?
Whether the facility ethics committee reached a consensus on the case
Whether the client's refusal is based on religious belief
Whether the client understands the risk of refusing the procedure
Whether the partner is client's durable power of attorney for health care
53
Nurse notices client received additional dose of medication. Which of the following actions should the nurse take first?
Notify the provider
Observe the client's condition
Complete an incident report
Inform the nursing supervisor
54
A nurse is teaching client how to use glucometer at home. Which of the following instructions should the nurse include?
Obtain the blood sample from the finger pads
Warm the hands prior to piercing the skin.
Elevate the arm for 1 min before taking the blood sample
Cap the lancet prior to putting it in the trash
55
A charge nurse is receiving change-of-shift report. Which of the following situations should charge nurse address first?
Two staff members have called to say they will be absent
nurse on the previous shift wrote an incident report about medication error
The emergency department nurse is waiting to give report on a new admission
Transport assistance is unavailable to take client to occupational therapy
56
Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management?
Complete required tasks
Document assessment data
Review the client's new laboratory values
Determine client care goals
57
Which of the following solutions should the nurse recommend to clean the equipment after CDIFF?
Isopropyl alcohol
Chlorine bleach
Triclosan
Chlorhexidine
58
The nurse suspects elder abuse. Which of the following actions should the nurse take?
File an incident report
Ask the client's son to go to the waiting area
Treat and discharge the client
Ask the client about his injuries with the son present
59
A nurse delegates vitals to an AP. Which of the following actions should the nurse take to evaluate the delegated task?
Ask the AP to write a summary of the delegated tasks during the shift
Review vital sign trends at the end of the shift
Recheck vital signs that are outside the expected reference range
Compare the vital signs with those taken by another AP on a previous shift
60
Which of the following clients should the nurse evacuate first?
A client who is confused and restrained for safety
A client who is receiving IV chemotherapy and is ambulatory
A client who is in Buck's traction for a left hip fracture
A client 1 day postoperative following thoracic surgery and chest tube
61
A charge nurse suspects staff nurse is chemically impaired. Which of the following actions should the charge nurse take?
Collect data about the staff nurse to support further action
Assign clients who are not prescribed narcotics to the staff nurse
Report the staff nurse to the facility ethics committee
Counsel the staff nurse about substance use
62
New nurse floats to unfamiliar unit and does not feel safe to care for clients. Which of the following actions?
Notify the risk manager.
Accept the assignment with help from assistive personnel on the unit
Document the concern in the nurse's notes
Request that the charge nurse modify the assignment
63
When using SBAR, which of the following information should the nurse include in the background portion of the report?
The client's code status
The client's name
A prescribed consultation
The client's vital signs
64
Two nurses having loud convo at nurses station about care for a patient. Which of the following actions?
Contact the house supervisor to mediate the conflict
Make arrangements to take over the client's care
Recommend that both nurses be terminated
Escort the nurses to the nurses' lounge to continue the discussion
65
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 bipolar disorder and is exhibiting signs of hallucination
A client who has major burns over 75% of her body surface area
66
Which of the following tasks should the nurse assign to a licensed practical nurse?
Perform a New Ballard screening
Conduct the newborn hearing screening
Administer a hepatitis B vaccine
Obtain vital signs
67
Which of the following information should the nurse include in the teaching as an example of advocacy?
Suggesting a client's partner attend a support group for emotional support
Recommending a referral for a client who requires physical therapy
Evaluating a client's home for safety hazards
Completing an incident report following a medication error
68
Nurse finds pile of newspapers in clients home+explains need to discard for safety+client agrees. What strategy was used
Accommodating
Compromising
Collaborating
Smoothing
69
The nurse should recognize that which of the following clients is the highest priority?
A client who has MRSA and an axillary temperature of 101F
newly diagnosed with pancreatic cancer and is scheduled to begin IV chemo
A client who is postop following a laminectomy 12 hr ago and cannot void
A client who has PVD and has an absent pedal pulse in the right foot
70
The nurse should explain that advance directives include which of the following?
Information regarding the disposition of the client's body upon death
Instructions regarding treatments the client desires or does not desire
Information regarding organ donation
A form with directions for contacting next of kin

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