ATI Houston Leadership 0316 Detailed Answer Key

1. A charge nurse allows two nurses who are arguing about who gets to go to lunch first, go together. The charge nurse agrees to cover both nurse’s client care. The charge nurse displayed which of the following types of conflict management? A. Avoiding Rationale: The charge nurse did not display avoiding, which is not to acknowledge or try to resolve the conflict. B. Competing Rationale: The charge nurse did not display competing, which is when the charge nurse would make quick or unpopular decision at the expense of another. C. Compromising Rationale: The charge nurse did not display compromising, which is when all parties involved are willing to give up something in the resolution of the conflict. D. Cooperating Rationale: The charge nurse did display cooperating, which is resolution of the conflict by sacrificing and allowing the staff nurses to get want. 2. A nurse in the cardiac catheterization lab implements a new procedure for achieving hemostasis of the cardiac catheter insertion site. Which of the following is a distinguishing characteristic of a new standard of care? A. Achievable Rationale: Achievable is a measurement tool for setting standards, not a characteristic. B. Measureable Rationale: Measurable is a measurement tool for setting standards, not a characteristic. C. Predetermined Rationale: Predetermined is used to distinguish the characteristic for implementing a new standard of care. D. Objective Rationale: Objective is a measurement tool for setting standards, not a characteristic. 3. A nurse manager received a client request not to have a particular nurse care for her while at the acute care facility. Which of the following is the most appropriate action by the nurse? A. Document the issue on an incident report. Rationale: The nurse manager documenting the issue on an incident report does not resolve the issue. B. Address the concern with the charge nurse. Rationale: The nurse manager addressing the concern with the charge nurse will help to resolve the issue by adjusting the assignments and then discussing the issue with the nurse that cared for the client. C. Explain to the client the nurse was having a bad day. Rationale: The nurse manager explaining to the client the nurses work load does not resolve the issue. D. Notify the human resources department. Rationale: The nurse manager notifying the human resources department does not resolve the problem. 4. A charge nurse is preparing to introduce a new type of infusion pump to the unit nursing staff. Which of the following statements by the charge nurse displays her as a change agent? A. “I want to let everyone know today we start using a new infusion pump.” Rationale: A change agent is an excellent communicator when change is impending, this statement is not characteristic of a change agent. B. “It is never too late to learn how to use a new infusion pump.” Rationale: A change agent is knowledgeable of available resources to meet the needs of change for the staff nurses, this statement is not characteristic of a change agent. C. “I think sometime this week we will have an in-service on the new infusion pump.” Rationale: A change agent plans ahead for education when a major change occurs, this statement is not characteristic of a change agent. D. “I want to remind everyone about the in-service on using the new infusion pump.” Rationale: A change agent organizes and prepare available resources when change is going to occur and informs the staff nurse of the change and education needed, this statement is characteristic of a change agent. 5. Which of the following examples display interpersonal conflict? A. Nurses on the day and night shift are conflicting regarding who should do client daily weights. Rationale: The nurses conflicting among themselves to make a client care decision is an example of intrapersonal conflict. B. Nurses throughout the hospital disagree on having 8-hour shifts or 12-hour shifts. Rationale: The nurses throughout an organization conflicting about length of shifts is an example of intergroup conflict. C. Nurse Jones is deciding between going to a professional meeting or attending a play. Rationale: The individual nurse is struggling to make a personal or professional decision, which is an example of intrapersonal conflict. D. Nurse Lee is professionally threatened by Nurse Doe. Rationale: The nurse who is threatened by another nurse may be experiencing bullying, this is an example of interpersonal conflict. Interpersonal conflict arises from differing goals and value system. 6. A nurse is teaching a newly licensed nurse methods to reduce costs of client care. Which of the following statements indicates understanding of the teaching? A. “I should discourage clients from taking as needed pain medications.” Rationale: The nurse should administer as needed pain medications upon client request to ensure management of a client’s pain. B. “I should perform perineal care on a client with an indwelling urinary catheter once a day.” Rationale: The nurse should perform perineal care on a client with an indwelling urinary catheter at least 3 times a day to decrease risk of infection. C. “I should encourage clients to receive an annual flu immunization.” Rationale: The nurse should encourage clients to receive an annual flu immunization to prevent the need for treatment and hospitalization necessary with influenza. D. “I should use non-sterile gauze to cover a client’s open wound.” Rationale: The nurse should use a sterile dressing to cover a client’s open wound to decrease the risk for infection. 7. A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available. Which of the following actions by the charge nurse displays conflict resolution? A. Use aggressive communication skills. Rationale: The charge nurse in conflict resolution should use assertive not aggressive communication skills. B. Assist the provider in identifying alternative solutions. Rationale: The charge nurse in conflict resolution should assist the staff nurse, not the provider, to identify alternative solutions. C. Address the situation as soon as possible. Rationale: The charge nurse in conflict resolution should address the situation as soon as possible to avoid escalation. D. Foster closed communication. Rationale: The charge nurse in conflict resolution should foster open communication, not closed communication, with the parties involved. 8. A nurse has received morning report on the following four clients. Which client should the nurse see first? A. A client who has a calcium level of 10 mg/dL and reports having a headache Rationale: This client is stable and does not require immediate attention. The calcium level is within the expected reference range of 9-10.5 mg/dL. Symptoms of hypercalcemia include increased heart rate and blood pressure, increased risk for blood clots, muscle weakness, and decreased deep-tendon reflexes. Signs of hypocalcemia include painful muscle spasms, and tingling and numbness in the hands and feet. The client’s report of a headache is unrelated to the calcium level and does not require immediate attention. B. A client who has a blood glucose of 68 mg/dL and reports mild sweating Rationale: The expected reference range for blood glucose is 70-110 mg/dL. This client is exhibiting an early sign of hypoglycemia. If untreated, the client’s condition will deteriorate. The client will require an immediate intervention. Early symptoms of hypoglycemia include sweating, irritability, anxiety, tachycardia, and hunger. Late symptoms include weakness, fatigue, confusion, and seizures. TIRED is an acronym for early signs: tachycardia, irritability, restlessness, extreme hunger, and diaphoresis. C. A client who has acute glomerulonephritis and reports reddish-brown urinary output Rationale: Acute glomerulonephritis is an inflammation of the glomerular capillaries. The expected symptoms include hematuria, decreased urine output, and proteinuria. Clients should consume a diet low in sodium and restrict fluid intake. This client does not require any immediate intervention because the findings are expected. D. A client who has cellulitis of the left lower extremity and reports pain in the affected leg Rationale: Cellulitis is a generalized infection in deep connective tissue with staphylococcus or streptococcus. It is usually a localized inflammation that may enlarge rapidly if not treated. Expected findings include redness, warmth, edema, tenderness, and pain. This client will require pain management and antibiotics, but this client is not the priority. 9. A nurse is assigned four postoperative clients. Which of the following clients should the nurse address first? A. A client whose capillary blood glucose at 0800 was 110 mg/dL and at 1200 is 98 mg/dL Rationale: The expected reference range for fasting capillary blood glucose is 70-99 mg/dL. The expected reference range for 1-hr postprandial capillary blood glucose is less than 140 mg/dL. The 0800 capillary blood glucose level is above the normal fasting level. Surgery is a stressor, and stressors elevate blood glucose levels, so it is not unusual for the capillary blood glucose level to be elevated. Because the 1200 capillary blood glucose level is at an expected level, this should not be of greatest concern to the nurse. B. A client whose wound drainage at 0800 was sanguineous and at 1200 is serosanguineous Rationale: Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pink (light red), watery, and a mixture of serum and blood. The change is expected as time passes and the wound heals. If the drainage had changed from serosanguineous to sanguineous, the nurse should suspect active bleeding or possible hemorrhage and should report this change to the RN or provider immediately. C. A client whose pain level on a scale of 1-10 at 0800 was a 2 and at 1200 is a 6 Rationale: Pain measurement is a subjective finding; it is whatever the client states it is. Intensity for a rating of 1-3 indicates mild pain, 4-6 indicates moderate pain, and 7-10 indicates severe pain. The stem does not give any information regarding when or if the client was medicated for pain. The nurse who evaluated the pain should treat in accordance to the client’s wishes and the provider’s prescriptions. It is not unusual for postoperative clients to experience pain. Therefore, this would not be of greatest concern to the nurse. D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg Rationale: Although the 0800 blood pressure is classified as prehypertensive (systolic 129-139 mm Hg or diastolic 80-89 mm Hg), it is not unusual for postoperative clients to have moderately elevated blood pressures related to the stress of surgery, pain, and IV fluid infusions. The 1200 blood pressure is considered normal (systolic 90-120 mm Hg and diastolic 60-80 mm Hg). The concern is the significant drop in the blood pressure, which could indicate internal bleeding. The licensed practical nurse should report this change to the RN for further assessment prior to notifying the provider. 10. A nurse is caring for a client who has dementia and receives delivery of a daily newspaper. The nurse observes a staff member reading the paper before it is given to the client. Which of the following actions by the nurse is appropriate? A. Report the incident to the unit manager.? Rationale: The newspaper is considered a client’s personal property. The staff member has violated the client’s rights. This action should be reported.? B. Purchase a new paper for the client.? Rationale: The purchase of another newspaper does not address the unprofessional behavior of the staff member.? C. Take no action at this time. Rationale: Immediate action is needed. The client’s rights have been violated, and the nurse should report the incident to the unit manager. D. Ask the family for permission to share with the staff. Rationale: The newspaper is the client’s personal property. The nurse should not ask a client or a client’s family to use personal property.