Riverside City College

NURSING MISC

1)A nurse manager is preparing to institute a new system for scheduling staff. Several nurses have verbalized their concern over the possible changes that will occur. Which of the following is an appropriate method to facilitate the adoption of the new scheduling system?

1. 1. Identify nurses who accept the change to help influence other staff nurses.
   2. Provide a brief overview of the scheduling system immediately before its implementation.
   3. Introduce the new scheduling system by describing how it will save the institution money. ATI Leadership Page 36
   4. Offer to reassign staff who do not support the change to another unit.

2. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway?
   1. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.
   2. A blood culture was obtained after antibiotic therapy had been initiated.
   3. The route of antibiotic therapy on the care pathway was changed from IV to PO.
   4. An allergy to penicillin required an alternative antibiotic to be prescribed. Rationale: ATI Leadership Page 38, 95, and 222.

3. A nurse should recognize that an incident report is required when
   1. A client refuses to attend physical therapy.
   2. A visitor pinches his finger in the client’s bed frame.
   3. A client throws a box of tissues at a nurse.
   4. A nurse gives a medication 30 min late. Rationale:ATI Leadership Page 95

4. Client satisfaction surveys from a surgical unit indicate that pain is not being adequately relieved during the first 12 hr post operatively. The unit manager decides to identify postoperative pain as a quality indicator. Which of the following data sources will be helpful in determining the reason why clients are not receiving adequate pain management after surgery?
   1. Prospective chart audit
   2. Retrospective chart audit
   3. Postoperative care policy
   4. Pain assessment policy Rationale:ATI Leadership Page 19

5. A nurse is precepting a newly licensed nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurse ask?
   1. “Did you secure the restraints to the side of the rails of the bed?”
   2. “Are you able to slip two fingers between the restraints and the client’s skin?”
   3. “Did you tie the restraints using a double knot?”
   4. “Are you removing the client’s restraints every 4 hours?” Rationale: ATI Leadership Page 81

6. A nurse is caring for an older adult client who has a stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant?
   1. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation.

1. 2. Provide the consultant with subjective opinions and beliefs about the client’s wound care.
   3. Request the consultation after several wound care treatments are tried.
   4. Arrange for the wound care nurse specialist to see the client daily to provide the recommendation treatment.

Rationale: ATI Leadership Page 40

7. A client is admitted with tuberculosis and placed in a negative pressure room. Which of the following nursing actions is appropriate?
   1. Notify the local health department of the admission.
   2. Place a sign on the client’s door with the diagnosis
   3. Ensure that admitting staff undergo PPD skin tests.
   4. Determine who had contact with the client in the last 48 hr. Rationale:ATI Leadership Page 62

8. A nurse is caring for a client who is unconscious and whose partner is his health care proxy. The partner has spoken with the provider and wishes to discontinue the client’s feeding tube. The provider states to the nurse, “I will not discontinue this client’s treatment. His partner has no right to make decisions regarding the client’s care.” Which of the following responses by the nurse is appropriate?
   1. “You should consider speaking with the facility’s ethics committee before making your decision.”
   2. “You have the right to make that decision, even if the partner is the client’s health care proxy.”
   3. “The client has designated his partner as health care proxy in his advanced directives.”
   4. “We’ll need to have the nursing supervisor review the client’s advanced directives.” Rationale: ATI Leadership Page 54

9. A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following information is most important for the nurse to report at shift change?
   1. Glasgow coma scale score
   2. Most recent blood glucose reading
   3. Laboratory tests scheduled for next shift
   4. Reddened area on the coccyx Rationale: ATI Leadership Page 6

10. A nurse is assigned the four following client’s for the current shifts. Which of the following clients should the nurse assets first?
    1. A client who has a hip fracture and is in buck’s traction
    2. A client who bas aspiration pneumonia and a respiratory rate of 28/min
    3. A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot
    4. A client who has a clostridium difficile infection and needs a stool specimen collected Rationale: ATI Leadership Page 7
11. A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take?
    1. Notify the nursing supervisor about the issue
    2. Contact the client’s physical therapist
    3. Apply a warm compress to the hip
    4. Reposition the client for comfort Rationale: ATI page 15

12. The mother of a client with breast cancer states, “It’s been hard for her, especially after losing her hair. And it has been difficult to pay for all the treatments.” Which of the following actions is appropriate client advocacy?
    1. The nurse investigates potential resources to help the client purchase a wig
    2. The nurse explains to the mother that most client’s with cancer lose their hair
    3. The nurse informs the next shift nurse regarding the mother’s concerns
    4. The nurse suggests counseling for the client’s body image issues

Rationale: ATI Leadership Page 51

13. Which of the following items must be discarded in a biohazard waste receptacle?
    1. A urinary catheter drainage bag from a client who is postoperative
    2. A bed sheet from a client with bacterial pneumonia
    3. A perineal pad from a client who is 24 hr post vaginal delivery
    4. An empty IV bag removed from a client who has HIV

Rationale:ATI Leadership Page 75

14. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t get better, I’m going to quit.” Which of the following responses by the unit manager is appropriate?
    1. so you are upset about all the changes on the unit
    2. I think you have a right to be upset. I am tired of changes too
    3. just stick with it a little longer. Things will get better soon
    4. you should file a written complaint with hospital administration Rationale: ATI Leadership Page 23

15. According to HIPPA regulation, which of the following is a violation of client confidentiality?`
    1. telephoning the pharmacy with a prescription for the spouse to pick up
    2. providing a copy of the record to the transporting paramedi c
    3. reporting a client’s disposition to the referring provider
    4. informing housekeeping staff that the client is in the dialysis unit.
16. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with sterile procedure. Which of the following actions indicates the nurse is maintaining sterile techniques (select all that apply)`
    1. opens the sterile pack by first unfolding the flap farthest from her body
    2. rests the cap of solution container upside down on the sterile field
    3. holds a bottle of sterile solution 15cm (6 inches) above the sterile field
    4. Places sterile items within a 1.25cm (.5inch) border around the edges of the sterile field.
17. A nurse is providing care for four postoperative clients. The nurse should assess the client`
    1. whose pulse has been steadily increasing during the past shift
    2. who is reporting pain level of 8 on a scale of 0-10
    3. whose urine output has averaged 32ml/hr for the past 24hrs
    4. Who is reporting nausea after the prescribed antiemetic was administered
18. A nurse is preparing to transcribe a client’s medication prescription in the medical record. Which of the following should the nurse recognize as containing the essential components o f a medication order
    1. NPH insulin 10 units before meals and at bedtime
    2. Haloperidol(Haldol)1mgbymouth
    3. Multivitamin every morning by mouth
    4. Aspirin 650mg by mouth every 4 hours

19. A nurse manager over hears a provider and a staff nurse talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first?
    1. Provide a staff in-service about client confidentiality.
    2. Report the incident to the nursing supervisor
    3. Remind them that client information is confidential
    4. Fill out an incident report regarding the situation.
20. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following?
    1. False imprisonment
    2. Battery
    3. Assault

20. 4. Libel
21. A nurse is preparing to discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the following information should the nurse include in the verbal transfer report?`
    1. Laboratory results within the expected reference range
    2. List of regularly prescribed medications
    3. Date of last bowel movement
    4. Level of consciousness
22. 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?`
    1. Review the client’s new laboratory values.
    2. Document assessment data.
    3. Complete required tasks
    4. Determine client care goals.
23. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
    1. “I will instruct visitors to wear a mask when visiting a client who is on contact precautions.”
    2. “I will place a client who has compromised immunity in a negative-pressure airflow room.”
    3. “I will wear a N95 respirator mask when caring for a client who is on droplet precautions.”
    4. “I will have a client who is on airborne precautions wear a mask when out of her room.”
24. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practical nurse?
    1. Changing the dressing on a postoperative wound
    2. Referring to a client to social services for assistance with transportation
    3. Instructing a client who is obese with a low-fat diet
    4. Providing the first oral feeding to a client following a stroke
25. A case manager working in a rehabilitation unit is discharging to home a client who has a spinal cord injury at vertebral level C-7. Which of the following is the priority action when creating the discharge plan? REPEAT
    1. Select strategies for cost-effective home care.
    2. Identify the client’s ability to perform activities of daily living.
    3. Provide educational handouts related to care requirements.
    4. Recommend community resources available to assist with client care.
26. A nurse is preparing to complete morning assessments on several assigned clients. Which of the following clients should the nurse plan to assess first? REPEAT
    1. A client who has a nasogastric tube to intermittent suction and reports nausea
    2. A client who has an early morning blood glucose of 220 mg/dL
    3. A client who had a bladder scan that indicated 250 mL of urine in the bladder
    4. A client who is 3 days postoperative and whose dressing has serosanguinous drainage
27. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? REPEAT
    1. Plan break times for assistive personnel.
    2. Pick up the meal trays after lunch.

C.    Administer a nasogastric tube feeding.

d.     Determine adequacy of ventilator settings.

28. A RN is planning client assignments for a licensed practical nurse (LPN) and three assistive personnel. The RN should assign the LPN to the client who requires REPEAT
    1. Recording of daily intake and output
    2. Assistance with meals
    3. A complete bed bath
    4. Frequent dressing changes.
29. Missing
30. A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel?
    1. Assessing a client who just returned from hemodialysis
    2. Reviewing dietary instructions for a client with kidney stones
    3. Obtaining a stool sample from a client with renal failure
    4. Monitoring a client with a fluid restriction
31. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
    1. Inform the unit manager of the incident
    2. Remove the restraints from the client’s wrists
    3. Speak with the AP about the incident
    4. Review the chart for non-restraint alternatives for agitation
32. A client is brought to the emergency department (ED) following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse?
    1. Document the client’s refusal in the chart REPEAT
    2. Tell the client that a catheter will be inserted
    3. Obtain a provider’s prescription for the blood alcohol level
    4. Assess the client for urinary retention
33. Nurses on an in-patient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan? REPEAT
    1. Use clean gloves rather than sterile gloves for colostomy care
    2. Wait to dispose of sharps container until they are completely full
    3. Return unused supplies from the bedside to the unit’s supply stock
    4. Store opened bottles of normal saline in a refrigerator for up to 48 hr
34. An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to an assistive personnel? REPEAT
    1. Turning the client
    2. Recording the client’s vital signs
    3. Determining the client’s pain level
    4. Checking the pulses of the client’s right food
35. To resolve the conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies is the nurse manager using? REPEAT
    1. Compromising
    2. Collaborating
    3. Cooperating
    4. Competing
36. A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?
    1. A client who has gestational diabetes and is receiving biweekly nonstress tests
    2. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
    3. A multigravida client who has preeclampsia and is receiving mistoprostol (Cytotec) for induction of labor
    4. A client who is at 32 weeks of gestation and has a premature rupture of membranes
37. A nurse working on a medical-surgical unit is managing care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
    1. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL

37. 2. A client who has Type 1 diabetes and uses an insulin pump
    3. A client who has orthostatic hypotension and is receiving IV fluids
    4. A client who is receiving heparin and has an aPTT of 34 seconds (On heparin: 45-80 sec) Rationale: https://quizlet.com/35490529/ati-normal-range-lab-values-flash-cards/
38. A charge nurse is assessing staff knowledge about safety procedures regarding needle stick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safety procedures? REPEAT
    1. “prophylactic treatment should be initiated after a needlestick during preparation of an injection.”
    2. “I should stop the bleeding as soon as possible following a needlestick injury.”
    3. “an incident report should be completed if a client receives a stick from her own used needle.”
    4. “the needle should be recapped to prevent injury during transport to the biohazard container.”
39. A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
    1. Obtaining a urine specimen from an older adult client (AP/CNA)
    2. Providing postmortem care for a client who has just died (AP/CNA)
    3. Accompanying a client who just had a wound debridement to physical therapy (AP/CNA)
    4. Reinforcing dietary teaching with a client who has heart disease
40. A nurse enters the room of a client who is unconscious and finds that the client’s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first? REPEAT
    1. Recommend the son meet with the provider to get information about his mother’s condition
    2. Complete an incident report regarding the breach of the client’s confidentiality
    3. Log out the computer so that the client’s son is unable to view his mother’s information
    4. Report the possible violation of client confidentiality to the nurse manager
41. A home health nurse is assessing the home environment of a client who is on continuous oxygen therapy. Which of the following findings requires the nurse to intervene?
    1. The oxygen machine has a grounded plug
    2. The family keeps a spare oxygen tank in the room
    3. The windows of the client’s room are open
    4. The client is covered with a woolen blanket
42. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include? REPEAT
    1. Elevate the arm for 1 min before taking the blood sample
    2. Cap the lancet prior to putting it in the trash
    3. Obtain the blood sample from the finger pads
    4. Warm the hands prior to piercing the skin
43. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? REPEAT
    1. Contact the client’s next of kin to obtain consent for treatment
    2. Proceed with treatment without obtaining written consent
    3. Have the client sign a consent for treatment
    4. Notify risk management before initiating treatment
44. A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include? REPEAT
    1. The client should avoid using a microwave oven to heat food
    2. Regular programming evaluations can be conducted by telephone
    3. the client should avoid using remote control devices to prevent dysrhythmias
    4. Swimming could cause the unit to have an electrical short
45. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take? REPEAT
    1. Reinforce the potential consequences of not having this information on record to the nursing staff
    2. Ask nurses who are caring for clients without this information in the medical record to obtain it.
    3. Meet with the nursing staff to review the policy regarding advance directives
    4. Remind nurses to obtain this information during the admission process
46. A client is admitted with COPD. Which of the following findings should the nurse report to the provider?

46. 1. Oxygen saturation 89% on room air
    2. White blood cell count 9,000/mm^3
    3. Report of dyspnea on exertion
    4. Bilateral crackles on auscultation of lungs
47. A charge nurse notices that two staff nurses are not taking meal breaks during their regular 8-hr shifts. Which of the following actions should the nurse take first?
    1. Providing coverage for the nurses’ breaks
    2. Determining the reasons the nurses are not taking scheduled breaks
    3. Discussing time management strategies with the nurses
    4. Review facility policies for taking scheduled breaks
48. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client’s care? (select all that apply.) REPEAT
    1. Occupational therapist
    2. Nutritional therapist
    3. Physical therapist
    4. Mental health counselor
    5. Case manager
49. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective? REPEAT
    1. “Guardian consent is required for an emancipated minor.”
    2. “Consent can be given by a durable power of attorney.”
    3. “A family member can interpret to obtain informed consent from a client who is deaf.”
    4. “The nurse can answer any questions the client has about the procedure”
50. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? REPEAT
    1. A client who is newly diagnosed with pancreatic cancer and scheduled to begin IV chemotherapy
    2. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
    3. A client who is postoperative following a laminectomy 12 hours ago and is unable to void
    4. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38 C (101 F)
51. A client is scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical units. Which of the following nursing statements is an appropriate nursing response?
    1. “It’s not too late to cancel the surgery if you want to.” REPEAT
    2. “This won’t take long and it will be over before you know it.”
    3. “Why did you make the decision to have this procedure?”
    4. “You shouldn’t be worried because the procedure is very safe”
52. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
    1. A client who has a raised red skin rash on his arms, neck, and face
    2. A client who reports right-sided flank pain and is diaphoretic
    3. A client who reports shortness of breath and left neck and shoulder pain
    4. A client who has active bleeding from a puncture wound of the left groin area
53. A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? REPEAT
    1. Review current literature regarding client falls
    2. Implement a fall prevention plan
    3. Notify staff of the increased fall rate
    4. Identify clients who are at risk for falls
54. A nurse is evaluating a newly licensed nurse who is administering a vitamin K. (Aquamephyton) injection to a newborn. Which of the following actions by the newly licensed nurse indicates understanding of the teaching? (Select all that apply.) REPEAT
    1. Selects the dorsogluteal site to administer the injections
    2. Cleans the injection site with alcohol
    3. Applies gentle pressure at the site after injection
    4. Aspirates the syringe for blood return after needle insertion