ATI Leadership | Exam 3 Study Guide Prioritization Questions
|Answers |Rationales
1. A nurse is caring for four clients on a medical-surgical unit. Which client
should the nurse assess first?
A. A client who had a hip arthroplasty 2 days ago and reports a pain level of 7 on a scale of 0 to 10.
B. A client who has a pneumonia and has a new onset of restlessness and confusion.
C. A client who has diabetes mellitus and a fasting blood glucose of 150 mg/dL.
D. A client who is scheduled for discharge and needs instructions on wound care.
Answer: B
Rationale: Restlessness and confusion are early signs of hypoxia, which relates to the
‘Breathing’ part of the ABC priority framework. This client requires immediate assessment
over stable or expected findings.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate for the nurse to delegate?
A. Assisting a stable client with post-operative ambulation.
B. Performing a sterile dressing change on a central line.
C. Evaluating a client’s response to pain medication.
D. Teaching a client how to use an incentive spirometer.
Answer: A
Rationale: APs can perform routine tasks for stable clients, such as ADLs and ambulation.
Evaluation, sterile procedures, and teaching are the responsibility of the RN.
,3. Which of the following conflict resolution strategies involves both parties
giving up something to reach a solution?
A. Competing
B. Compromising
C. Avoiding
D. Collaborating
Answer: B
Rationale: Compromising involves a ‘give-and-take’ where both parties sacrifice
something to reach a middle ground. Collaborating is a win-win where both parties work to
meet all goals.
4. A nurse manager is using the Lewin’s Change Theory to implement a new
charting system. Which action represents the ‘unfreezing’ stage?
A. Providing training sessions to staff on the new software.
B. Informing staff about the inefficiencies of the current system to build a need for change.
C. Evaluating the effectiveness of the system after one month.
D. Supportively coaching staff who are struggling with the transition.
Answer: B
Rationale: Unfreezing involves creating awareness of the need for change and preparing
the group to let go of the current status quo.
5. During a mass casualty incident, which client should be assigned a red tag?
A. A client with a simple fracture of the radius.
B. A client with an obstructed airway requiring immediate intervention.
C. A client with a large open abdominal wound and stable vitals.
D. A client with an agonal respiratory pattern and fixed pupils.
Answer: B
Rationale: Red tags are for immediate threats to life, such as airway obstruction or shock.
Agonal breathing is black (expectant), and simple fractures are green (minor).
, 6. A nurse is planning to delegate care for a client who has a colostomy to a
licensed practical nurse (LPN). Which task can the LPN perform?
A. Developing the initial plan of care for the client.
B. Assessing the stoma for signs of ischemia immediately post-op.
C. Administering a bolus enteral feeding through a gastrostomy tube.
D. Teaching the client’s family how to change the appliance.
Answer: C
Rationale: LPNs can perform routine tasks like enteral feedings. Assessment and initial
teaching are RN responsibilities.
7. A nurse is preparing an incident report after a client fall. Which of the
following should the nurse include in the report?
A. Personal opinion on why the client fell.
B. Factual description of the event and the client’s status.
C. The fact that an incident report was filed in the medical record.
D. Names of the staff members who were on break at the time.
Answer: B
Rationale: Incident reports should be objective and factual. You should never document in
the medical record that an incident report was completed.
8. A nurse is caring for a client who is refusing a blood transfusion for religious
reasons. Which ethical principle is the nurse upholding?
A. Beneficence
B. Nonmaleficence
C. Justice
D. Autonomy
Answer: D
Rationale: Autonomy refers to the client’s right to make their own decisions about their
healthcare, even if those decisions conflict with medical advice.
|Answers |Rationales
1. A nurse is caring for four clients on a medical-surgical unit. Which client
should the nurse assess first?
A. A client who had a hip arthroplasty 2 days ago and reports a pain level of 7 on a scale of 0 to 10.
B. A client who has a pneumonia and has a new onset of restlessness and confusion.
C. A client who has diabetes mellitus and a fasting blood glucose of 150 mg/dL.
D. A client who is scheduled for discharge and needs instructions on wound care.
Answer: B
Rationale: Restlessness and confusion are early signs of hypoxia, which relates to the
‘Breathing’ part of the ABC priority framework. This client requires immediate assessment
over stable or expected findings.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate for the nurse to delegate?
A. Assisting a stable client with post-operative ambulation.
B. Performing a sterile dressing change on a central line.
C. Evaluating a client’s response to pain medication.
D. Teaching a client how to use an incentive spirometer.
Answer: A
Rationale: APs can perform routine tasks for stable clients, such as ADLs and ambulation.
Evaluation, sterile procedures, and teaching are the responsibility of the RN.
,3. Which of the following conflict resolution strategies involves both parties
giving up something to reach a solution?
A. Competing
B. Compromising
C. Avoiding
D. Collaborating
Answer: B
Rationale: Compromising involves a ‘give-and-take’ where both parties sacrifice
something to reach a middle ground. Collaborating is a win-win where both parties work to
meet all goals.
4. A nurse manager is using the Lewin’s Change Theory to implement a new
charting system. Which action represents the ‘unfreezing’ stage?
A. Providing training sessions to staff on the new software.
B. Informing staff about the inefficiencies of the current system to build a need for change.
C. Evaluating the effectiveness of the system after one month.
D. Supportively coaching staff who are struggling with the transition.
Answer: B
Rationale: Unfreezing involves creating awareness of the need for change and preparing
the group to let go of the current status quo.
5. During a mass casualty incident, which client should be assigned a red tag?
A. A client with a simple fracture of the radius.
B. A client with an obstructed airway requiring immediate intervention.
C. A client with a large open abdominal wound and stable vitals.
D. A client with an agonal respiratory pattern and fixed pupils.
Answer: B
Rationale: Red tags are for immediate threats to life, such as airway obstruction or shock.
Agonal breathing is black (expectant), and simple fractures are green (minor).
, 6. A nurse is planning to delegate care for a client who has a colostomy to a
licensed practical nurse (LPN). Which task can the LPN perform?
A. Developing the initial plan of care for the client.
B. Assessing the stoma for signs of ischemia immediately post-op.
C. Administering a bolus enteral feeding through a gastrostomy tube.
D. Teaching the client’s family how to change the appliance.
Answer: C
Rationale: LPNs can perform routine tasks like enteral feedings. Assessment and initial
teaching are RN responsibilities.
7. A nurse is preparing an incident report after a client fall. Which of the
following should the nurse include in the report?
A. Personal opinion on why the client fell.
B. Factual description of the event and the client’s status.
C. The fact that an incident report was filed in the medical record.
D. Names of the staff members who were on break at the time.
Answer: B
Rationale: Incident reports should be objective and factual. You should never document in
the medical record that an incident report was completed.
8. A nurse is caring for a client who is refusing a blood transfusion for religious
reasons. Which ethical principle is the nurse upholding?
A. Beneficence
B. Nonmaleficence
C. Justice
D. Autonomy
Answer: D
Rationale: Autonomy refers to the client’s right to make their own decisions about their
healthcare, even if those decisions conflict with medical advice.
