ATI RN LEADERSHIP PROCTORED EXAM VERSION 1, 2 &3 COMPLETE TEST

ATI Leadership Proctored Exam 1. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should thenurserecommend for an interdisciplinary care conference? 2. A nurse is preparing to discharge a client who has end stage heart failure. The clients partner tells thenurse she can no longer handle caring for the client. Which of the following actions should the nurse take? 3. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma.The parent states she is unable to afford the nebulizer prescribed for the child. Which of the followingreferrals should the nurse recommend? 4. A nurseis supervising assistive personnel who’s feedinga client with dysphagia. Which of thefi ollowing actions bythe AP shouldthe nurse identify as correct technique? 5. A nurse is providing anin-service about client rights for a group of nurses. Which of the followingsi tatements should the nurse include in the in-service? 6. A nurseis preparingto discharge a client who requires home oxygen. The equipment company hasnot yet delivered the oxygentank. Which of the following action shouldthe nurse take? 7. A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she hasreconsidered becauseshe is worried about the pain. Which of the following response bythe nurse is appropriate? 8. A nurse in a long-term care facility is caring for a client and witnessed the assistive personnel positionhiminbed with excessive force. Whichof thefollowing actions should the nurse take? 9. A nurseis assessingaclient who has meningitis. Which of the followingfindingshouldthe nurseri eport to the provider immediately? 10. A nurseis caringfora client who wanders throughthe halls yellingobscenities at staff other clientsand visitors. Which action should the nurse take? A) Administer sedatives B) Keepthe client in her room with the door closed C) D) Placethe client in a wheelchair witha lap tray 11. A nurseis assisting with the orientation of a newly licensed nurse. The newly licensed nurse is havingtrouble focusing and had difficulty completing care for his assigned client. Which of the following intervention is appropriate ATI RN LEADERSHIP PROCTOREDEXAM 2023 VERSION 1, 2, 3 S - The Marketplace to Buy and Sell your Study Material 12. A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bonecancer toan experienced AP. Which of the followingassessment should the nurse make beforedelegatingcare? 13. A nurseis participating in the development of a disaster management plan for a hospital. The nurseshould recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event? . 14. A nursemanger observes anassistive personnel incorrectlytransferring a client tothe bedsideicommode. Which of the following actions shouldthe nurse take first? 15. Anursemanager is leading discussion about ethical dilemmas. Which of the following situationssi houldthe nurse manager include as an example of an ethical dilemma? A) a nurse witnesses another nurseadminister incorrect medication B) a visitor experiences minor burns at afacilityafter receiving…. C) D) aclient receives operation on the wrong side of thebody 16. Anursea caringfor aclient who request information about the prevalence of Tay-Sachs disease.Which of the following resources shouldthe nurse useto obtain this information? 17. A nurseis orienting a newlylicensed nurseabout client confidentiality. Which of the followingstatement bythe newlylicensed nurse indicates an understanding of the teaching? 18. A nurse in the emergency department is assessing a client who is unconscious following a motor- vehiclecrash. Theclient requires immediate surgery. Which of the followingactions shouldthe nurseitake? 19. A nurseenters a clients roomto witness aninformed consent for a gastroscopy. The client states hedoes not understand the procedure. Which of the following actions should the nurse take? 20. Acasemanager is preparinga discharge plan for a client followingcoronary artery bypass graphingisurgery. Which of the following client issues should the nurseaddress first? 21. A nurseina clinic is reviewing laboratoryreports for a group of clients. Which of the followingdi iseases should the nurse report to the state health department? Pertussis 22. A nurseis preparingtocomplete anincident report regardinga medication error. Which of thefollowing actions should the nurseplan to take SATA. A. Placea copy of the completed report in the client’s medical record B. Make a copy of theincident report for personal record keeping C. D. E. Obtainand order fromthe client’s provider tocomplete the report 23. Acharge nurse onan obstetrical unit is preparingthe shift assignment. Which of thefollowing clientsshould be assigned to an RN who has floated froma medical-surgical unit? 24. A nurse in the emergency department is preparing to carefor a client who arrived via ambulance. Theiclient is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? 25. A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a licensedpractical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? 26. A nurseworking on a medical-surgical unit is managing careof four clients. The nurse shouldschedulean interdisciplinary conference for which of the followingclients? 27. A nurse entersthehallway anddiscovers a visitor lookingat a clients medical information on thecomputer. Which of the following actions shouldthe nurse take first? 28. A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take? 29. A nurseis caringfor a client who is unconscious and whose partner is their healthcaresurrogate. Thepi artner wishes to discontinue the client’s feeding tube, but another family member tells the nurses they want the client to continue receiving treatment. Which of the following responses should the nurse make? 30. A nurse is caring for a client who reports acutepain but refuses IM medication. The nurse distractsti heclient and quickly administers the injection. This illustrates which of the following? Battery 31. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary teamimembers shouldbeconsulted in regardto this client’s care? (select all that apply.) 32. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the followingstatements bythe newlylicensed nurseindicates understanding of isolation guidelines? 33. Nurses on an inpatient careunit are workingto help reduce unit costs. Which of thefollowing isappropriate to include in the cost-containment plan? 34. A nurse is caringfor a client who has cancer. The client’s adult child asks the nursefor informationabout theclient’s treatment plan. Which of the followingresponses shouldthenurse make? 35. A nurse inthe emergency department is performing triage for a group of clients who wereina trainicrash. Which of the following clients should the nurse tag as emergent? A) Aclient who has a deep partialthickness burn on the lower extremities B) Aclient who has an open fractureof the femur D) Aclient who has a peri fatal ecchymosis 36. A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses,but the client’s partner wants the surgery performed. Which of the following is the deciding factor indetermining if the surgery will be done? 37. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actionssi houldthe nurse take? 38. A nursemanager is receivingreport and is facedwiththe following situations that requiresiintervention. Which of the following should the nurse manager address first? a. A nurse on theprevious shift wrote anincident report about a medication error. b. Two staff members have called to say they will be absent. c. Transport assistance is unavailabletotake a client to occupational therapy. d. 39. 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? 40. A nurse is receiving a verbal prescription fromthe provider for a client who is havingincrease pain.The nurse shouldtranscribe which of the following prescription in the client’s medical records? It isn’t thetwo with the 4oand not the onethat says 10.0 mgIt’slike “Morphine sulfate 10 mg IV q 4 hr for pain” 41. Anurseworkinginthe emergencydepartment is assessing several clients. Which of the followingci lients is the highest priority? 42. A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation(TENS). Which of the following members of the interdisciplinary team should the nurse contact forassistance? 43. A nurseis teachinga newly licensed nurse about implementingdroplet precautions for a client whohi as influenza. Which of the following statements by the newly licensed nurse indicates and understandingof the teaching? 44. A nurse is caringfor four clients. Which of the followingclients shouldthe nurse assess first? restlessness 45. A nurse is developing a discharge plan for a client who is post-operative and will require a wheelchair inthe home. The nurse shouldplace a referral to which of the followingresources toobtain the clients prescription? A) Home health B) Physicaltherapy C) Occupational therapy D) (Pg 26) 46. A nurse is working on a quality improvement team that is assessing an increase in client falls at a facility. After problem identification, which of the following actions should the nurse plan to takeifirst as part of the quality improvement process? 47. A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the followingtriagetagcolor should the nurseinstruct the group toapply to a clientwho has full thickness burn on 72% of his body? 48. A nurse has just completed assessment charting on an electronic medical record for an assigned client. An assistivepersonnel who just measured the clients vital signs askedto chart themwhile thenurse is still logged in. Which of the followingactions should the nurse take? 49. A nurse is caringfor a client who has been admittedand diagnosed withtype 1 diabetes mellitus. theiclient tells the nurse she has decided to go home. Which of the following action should the nurse take? 50. A nurseis anambulatory care settingis orientinga newly licensed nurse who is preparing to return acall to a client. The nurse should explainthat which of the followingis an objective of telehealth? a. b. Providing medicationreconciliation c. Developingclient treatment protocols d. Establishingcommunicationbetween providers 51. A nurseis delegating carefor a group of clients. Which of the followingclients should the nurseassign to a licensed practical nurse? A) a client who is scheduledfor an endoscopylater todayand requires enema B) C) a newlyadmitted client whohas diabetes mellitus andrequires initial teaching onself- administrationof insulin D) a newly admittedclient who has sicklecell anemia requires a development of aninitial planof care 52. A nurseinthe emergencydepartment admits a client who has been exposed to cutaneous anthrax.Which of the following actions should the nursetake? 53. A nurseon a surgical unit is preparingtotransfer a client to a rehabilitation facility. Which of thefi ollowing information should the nurse include in the change of shift report? 54. A nurse on a medical surgical unit is evaluating an assistive personnel use of infection control precaution. Which of the following actions by the assistive personnel indicates correct use ofprecaution? 55. A nurseon a med surg unit is caringfor a client who asks about advance directives and states that hewants to appoint a health careproxy. Which of the followingresponses shouldthe nurse make? 56. A nurse is teachingnewly licensed nurseabout client confidentiality. Thenurseshould include thatwhich of the following examples represents a violation of client confidentiality? 57. A nurse is providingchange-of-shift report for anoncoming nurse. Which of the followinginformationshould the nurse include in the report? 58. A nurseis preparinga teaching session witha client who speaks a different language thanthe nurse.Which of the following interventions should the nurse plan to take? 59. Acharge nurse witnessed anassistive personnel failing to follow facility protocol when discardingcontaminatedlinens. Which of the following actions should the nurse take first? 60. A nurseon a medical-surgical unit is caringfor four clients. The nurse should recognize that which ofthefollowing client is the highest priority? 61. A nurse inthe emergency department is preparing to carefor a client who arrived via ambulance. Theci lient is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? 1. Have theclient sign aconsent for treatment 2. Notifyrisk management before initiatingtreatment 3. Proceed withtreatment without obtaining written consent (Implied Consent) 4. 62. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in thecrash, and avoided urine specimen is ordered. Theclient repeatedly refuses to providethe specimen. Which of the following is the appropriateaction bythe nurse? a.Tell the client that a catheter will . c. Assess the client for urinaryretention. d. Obtaina provider’s prescriptionfor a blood alcohol level. 63. A nurse is planningcarefor a group of clients and can delegate care to a licensed practical nurse(LPN) andan assistive personnel. Which of the following tasks shouldthe nurseassign to the LPN? 1. 2. Ambulatinga client who is scheduled for discharge later in the day 3. Administeringmorphine IVbolus toa client who is hr postoperative 4. Admittinga newclient who has chronic back pain to the unit 64. A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurseadministers the prescribed opioidandbenzodiazepine, the client becomes somnolent and difficult toai rouse. Which of the following actions should the nurse take? 1. Withholdthe benzodiazepine but continuethe opioid. 2. Contact the provider aboutreplacing the opioid withan NSAID. 3. Administer the benzodiazepine but withholdtheopioid. 4. 65. A nurse is preparinga client for an elective mastectomy. Theclient is wearing a plain gold weddingband. Which of thefollowing is an appropriateprocedure for taking careof this client’s ring? 1. 2. Tape the ringsecurelytotheclient’s finger. 3. Placethering in the bagwith the client’s clothing. 4. Agreeto keep the ringfor the client until after surgery. 66. A nurse inanurgent careclinic is admittinga client who has been exposedtoa liquid chemical in anindustrial setting. Which of the following actions should the nurse take first? a. b. Irrigate the exposed area with water c. Removethe client’s clothing d. Reportthe incident to OSHA 67. A nurse manager is making staffing assignments for the maternal newborn unit. Which of thefi ollowing clients shouldthe nurse manager assign to a float nursefromthe medical-surgical unit? 1. Aclient who is post termandis receivingoxytocin for labor induction 2. Aclient who gave birth to her first child and requires instruction on breastfeeding techniques ambulating 4. Aclient who has preeclampsia andis receivinga continuous magnesiumsulfateinfusion 68. A nurse is assisting with triage duringa mass casualtyevent. The nurse applies a red tagto a client.Which of the following actions should the nurse take? 1. Treat the client’s injuries within30 min 2. 3. Providetreatment for minor injuries 4. Allowtheclient to die without further intervention 69. To receive a conflict between staff members regarding potential changes in policy, a nurse manager decides toimplement thechanges sheprefers regardless of the feelings of those who opposethosechanges. Which of thefollowing conflict-resolution strategies is the nurse manager using? 1. Compromising 2. Cooperating 4. Collaborating 70. A nurseon a medical-surgical unit is caringfor four clients. Which of thefollowing findings isithe highest priority? 1. iseconds 2. Aclient who has COPD andhas an oxygen saturation of 90% 3. Aclient who hada cholecystectomy 6 hr ago and is requesting pain medication 4. Aclient whose TPNwas discontinued 4 hr ago and is requestingclear liquids S - The Marketplace to Buy and Sell your Study Material ATI RN LEADERSHIP PROCTORED EXAM 2019 VERSION 3 1. A nurse is assessing a school-age child who has heart failure and is takingfurosemide. Which of the following findings should the nurse identify as an indication thatthe medication is effective? a. An increase in venous pressure c. a decrease in cardiac output d. an increase in potassium levels 2. A nurse is assessing an infant who has acute otitis media. Which of thefollowing findings should the nurse expect (select all that apply) a. Increased appetite b. enlarged subclavian lymph nodeic. iCrying d. 3. a nurse is providing teaching to the parents of an infant who is to undergopilocarpine lontophoresis Testing for Cystic Fibrosis. Which of thefollowing statementsshould the nurse include in the teaching? a. We will measure the amount of protein in your baby's urine over 24 hourperiod b. c. a nurse will insert an IV prior to the test d. your baby will need to fast for 8 hours prior to the test 4. A nurse in an urgent care clinic is prioritizing care for children. Which ofthe following children should the nurse assess first? a. A toddler who has nephrotic syndrome and facial edema b. c. a preschool-age child who has diabetes mellitus and a blood glucose of NURSING TEST BANK 200 mg/dL d. an adolescent who has Crohn's disease and recent weight loss of 5kg mgi(11 lb) 5 .A nurse is providing teaching to the parents of a toddler who is to undergoa sweat chloride test. Which of the following statements should the nurse include? a. The purpose of the test is to determine if your child has Crohn's disease b. the technician will use a device to produce an electrical current during theitest c. during the test, your child will be in a room thatis coldid. 6. A nurse in the emergency department is caring for an adolescent who is requesting testing for STI. Which of the following action is appropriate for thenurse to take? a. Request verbal consent from the social worker b. contact the client's parents to obtain phone consent c. postpone the testing until the client's parents are presentid. iobtain iwritten iconsent ifromithe iclient 7. A nurse in the emergency department is assessing the toddler who hashyperpyrexia severe dyspnea and drooling which of the following actions should the nurse take first? a. obtain a blood culture from the toddler b. administering antibiotic to the toddler c. insert an IV catheter for the toddler d. 8. A nurse is providing teaching to a 10 year old child with scheduled for an arterial cardiac catheterization. Which of the following information should thenurse include in the teaching? a. You will have your dressing removed 12 hours after the procedurei procedure c. you will be on a clear liquid diet for 24 hours following the procedure d. you will be on bed rest for 2 days after the procedure9. 10. A nurse is caring for a preschooler who is post-operative following atonsillectomy. The child NURSING TEST BANK is now ready to resume oral intake which of the following dietary choicesshould the nurse offer the child? a. sugar-free Cherry gelatin b. vanilla ice cream c. chocolate milk d. 11. A nurse is caring for an infant who has Patent ductus arteriosus. Thenurse should identify that the defect is a switch of the following locations of the heart. ( you willfind hot spots to select in the artwork below. Select only the hot spot that corresponds to youranswer)Answer: B 12. A nurse is caring for a 10 month old child was brought to the emergencydepartment by his parents following a head injury. Which of the following actions should the nurse take first? a. Inspect for fluid leaking from the ears (thinking about CSF leakage severetrauma = urgent, after respiratory status is confirmed) b. c. check pupil reactions d. examine the scalp for lacerations 13. A charge nurse is planning care for an infant who has failure to thrive. Which of the following actions should the nurse include in the plan of care? a. Assign consistent nursing Staff Care for the infant b. Keep infant in a visually stimulating environmenti d. give theinfant fruit juice between feedings 14. A nurse is providing teaching about home care to the parent of a child who has scabies. Which of the following instruction should the nurse includein the teaching? a. Wash your clients hair with shampoo containing Ketoconazoleib. c. apply petroleum jellytothe affected areas d. treat everyone who came into close contact with a child 15. A nurse is caring for a preschooler who refuses to take a start dose of NURSING TEST BANK oral diphenhydramine. Which of the following statements should the nurse make? a. b. let me know when you want to take the medication c. the medication will treat your hypersensitivity reaction ( too much “Adult”terminology/ jargon for pre schooler to understand) d. sometimes, when a child has to take medication, they feel sad. 16. A nurse is teaching the parent of a school-age child about bicycle safety.Which of the following instructions should the nurse include in the teaching? a. b. your child's feet should be three to six inches off the ground when Seatedon the bicycle c. you should try to keep the bicycle at least three feet from the curb whileriding in the street d. your child should ride the bicycle against the flow of traffic 17. A nurse is caring for a school-age child following the application of a castto a Fractured right tibia. Which of the following actions should the nurse take first? a. Teach the child about cast care b. Pad the edges of the cast c. administer pain medicationid. iElevate ithe 18. 19. A nurse is preparing a school-age child for an invasive procedure. Whichof the following actions should the nurse plan to take? a. b. use vague language to describe the procedure c. explain the procedure to the child when they are in the playroom d. demonstrate deep breathing and Counting exercises20. 21. A nurse is preparing to collect a urine specimen from a female infant using a urine collection bag. Which of the following actions should the nursetake? NURSING TEST BANK -Apply lidocaine gel to the perineum before attaching the bag -Position the opening of the bag over the urethra and the anus -Place a snuff fitting diaper over the drainage bag 22. A nurse is planning care for a toddler who has developed oral ulcers inresponse to chemotherapy. Which of the following actions should the nurse include in theiplan of care? a. Schedule routine Oral Care every 8 hours b. c. more sending me closer with lemon glycerin swabs d. administer oral viscous lidocaine 23. A nurse is providing discharge teaching to the parents of an infant who isat risk for sudden infant death syndrome (SIDS). Which of the following statements by the parent indicates an understanding of the teaching? a. I will have my baby sleep next to me in the bed during the night b. Elmo my baby stuffed animal to the corner of her crib while she sleepsic. d. I will lay my baby on her side to sleep for her naps 24. A nurse is monitoring an infant who is receiving opioids for pain. Which ofthe following findings should indicate to the nurse that the medication is having a therapeutic effect? a. Increased blood pressure b. Limb withdrawal c. d. bradycardia 25. A nurse is caring for a three-month-old infant who has cleft of the softipalate. Which of the following actions should the nurse take? a. b. postpone burping the infant until after completing each feeding c. Elevate the infant’s head to a 10 degree angle during feedings d. Feed the infant 177.4 ml (6 oz) of Formula 3 times a day 26. A nurse is caring for a child who has hyponatremia. Which of thefollowing findings should the nurse expect? a. Tetany NURSING TEST BANK b. weight gain c. Elevated heart rate d. excessive diaphoresis 27. A nurse is preparing to administer an enteral feeding to an adolescent who has an NG tube. Which of the following actions should the nurse take first? a. Set the administration rate on the feeding pump b. flushthe tube with water c. check the pH of the gastric secretion d. 28. A nurse is caring for an adolescent who is 1 hour post-operative followingan appendectomy. Which of the following findings should the nurse report to theprovider? a. Heart rate 63 / minuteib. imuscle i rigidity c. temperature 36.4 Celsius (97.5 Fahrenheit) d. abdominal pain 29. A nurse in a provider's office is preparing to administer immunization to a12 year old client during a well-child visit. Which of the following immunization should the nurse plan to administer? a. Diptheria,itetanusiandipertussisi(D-Tap) b. human papillomavirus (HPV) c. Varicella d. hepatitis A 30. Nurse is planning care for an 8 month old infant who has heart failure.Which of the following actions should the nurse include in the plan of care? a. Repeat digoxin dosage is the infant vomit within 1 hour of administration b. Place infant in a prone position c. d. provide less frequent, higher volume feeding 31. A nurse is planning care for a school-age child who is admitted from theemergency department 12 hours ago. Which of the following interventions should the nurse include to promote adequate sleep for the child? a. Provide the child with video games prior to bedtime to reduce stress NURSING TEST BANK b. allow the child to adjust their bedtime to promote autonomy NURSING TEST BANK c. leave the lights on in the child's room to promote safetyi 32. A nurse is preparing to initiate IV antibiotic therapy for a newly admitted12 month old infant. Which of the following actions should the nurse plan to take? a. cover the insertion site with an opaque dressingib. iuse ia i24 igauge icatheter ito istart ithe iIV c. start the IVon the infant’s foot d. change the IV site every 3 days 33. A nurse in a pediatric clinic is providing teaching to the guardian of an infant who has a new prescription for digoxin. Which of the following manifestations should the nurse include as an indication of digoxin toxicity? a. Diaphoresis b. Polyuria c. Bradycardia d. jaundice 34. A nurse is preparing to administer amoxicillin 80 mg/kg/day divided intotwo doses daily to a 2-year-old client who weighs 10 kg (22 lb). Available is amoxicillin suspension 400 mg/5 mL. how many mL of amoxicillin should thenurse administer per dose? (Round the answer to the nearest whole number.Use a leading zero if it applies. Do not use a trailing zero.) 10ml 35. A nurse is reviewing the laboratory results of a child was recently admitted or suspected rheumatic fever. The nurse should identify that whichof the following laboratory tests can contribute to confirm this diagnosis (select all that apply) a. partial thromboplastin time (PTT) b. erythrocyte isedimentation iratei(ESR) c. blood urea nitrogen (BUN)id.iC-reactive iprotein ) 36. A nurse is teaching a group of female adolescents about healthy eating.Which of the following instructions should the nurse include in the teaching? a. NURSING TEST BANK b. limit your sodium intake to 3000 mg per day c. consumer 1,500 to 1700 calories per day d. decrease your vitamin D intake once you start to menstruate 37. A nurse is caring for an infant who receives intermittent enteral feedingthrough a gastrostomy tube. Which of the following actions should the nurse take whenadministering a feeding? Select all that apply a. b. formula to 39° C (102 degrees Fahrenheit ) prior to Administrationic. d. instill the formula over a period Of 30 and 45 minutes 38. A nurse is planning care for a child who has osteomyelitis. Which of thefollowing interventions should the nurse include in the plan of care? a. Encourage frequent physical activity to increase bone mass b. maintain patent intravenous catheter d. provide a high calorie low protein diet 40. A nurse is providing teaching to the guardian of a school-age child whohas sickle cell disease about management of the illness. Which of the following instructions should the nurse include? a. Apply cold compress to painful areas b. but I shall wear a surgical mask to schooli d. offer fluids of bedtime 41. A nurse is assessing a 5 month old infant. Which of the following findingsshould the nurse report to the provider? a. Unable to hold a bottle b. exhibits head lag when pulled a sitting position c. absent grasp reflex d. 42. A nurse is caring for a five-year-old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify asan indication of hemorrhage? a. Flushing of the face NURSING TEST BANK b. c. d. 43. blood pressure 99/ 56 mmhg heart rate 54/ minutes A nurse is discussing coping mechanisms with a parent of a three-month- old infant which of the following therapeutic questions should the nurse ask the parent? a. What do you do when your infant is fussy? b. Are you willing to take new parenting classes? c. Does parenting cause you stress? d. 44. A nurse is providing teaching about the effects of sun exposure to a parent of a toddler. which of the following responses by the parent indicatesan understanding of the teaching? a. my child should wear a wide-brimmed hat b. my child should remain under a beach umbrella umbrella during morninghours c. I should apply 10 SPF sunscreen to my child's entire bodyid. iI ishould idress imy ichild iin iloose iactiveiclothing 45. A nurse is evaluating a 6 year old child who has cystic fibrosis and hasbeen receiving chest physiotherapy treatment. The nurse should identify which of the following findings as an indication of the therapy has been effective? a. Increased urine output c. reduced pain d. increased heart rate 46. A nurse is planning care for a six-month-old infant who has bacterial meningitis. Which of the following interventions should the nurse include inthe plan of care? a. b. keep the television on in the room to provide background noise c. Padthe side rails of the crib d. provide for you can range of motion to the neck and shoulders 47. A nurse is reviewing the medical record of a child with cystic fibrosis which of the following should the nurse report to the provider? Click on theexhibit button for additional information about the client. NURSING TEST BANK a. heart rate b. HbA1c c. oxygen saturation d. WBC48. 48. A nurse is assessing an infant who has severe dehydration due to gastroenteritis which of the following findings should the nurse expect? a. b. capillary refill of 2 seconds c. Hypertension d. increased urine output 49. A nurse is assessing an infant who has intussusception. Which of thefollowing findings should the nurse expect? a. b. board like abdomen c. Constipation d. increased urinary output 50. A nurse is caring for a 14 year old adolescent who has a cast on the rightarm and swelling of their right hand. The nurse elevates The Adolescents affected extremity. The nurse should identify that which of the following findings is an indication that the intervention has been effective? a. The Adolescent reports of the cast feels tight b. The Adolescents hands feel cool to touch c. d. the Adolescent reports feeling tingling in their arms 51. A nurse in a provider's office is assessing the vital signs of a two-year- oldchild at a well-child visit. Which of the following findings should the nurse report to theprovider? a. Respiratory rate 26 / min b. pulse rate 98 / minutes c. temperature 37.2 Celsius (99 Fahrenheit)id. iblood ipressure i118 i/ i74 52. A nurse is preparing to administer a prescribed medication to a toddler whose parent is nearby. Which of the following actions should the nurse taketo identify the toddler? NURSING TEST BANK a. check the toddler's room number against their ID bandi c. ask the parent to confirm the toddler's identity d. ask another nurse to confirm to toddlers identity 53. A nurse is teaching home care to the parents of a preschool-age child who has heart failure. Which of the following information should the nurseinclude in the teaching? a. Weight the child once each month month b. withhold digoxin of the child's pulse is greater than 100 / minutesic. d. increase the child's oxygen flow rate until the child no longer has cyanosis 54. A nurse in the PACU is caring for a school-age child immediately followinga tonsillectomy. Which of the following actions should the nurse take? a. b. offerthe child ice cream when alert c. instruct a child to drink fluids through a straw d. encourage the child to deep breathe and cough 55. A nurse is reviewing the medical record of a 15 month old child who isscheduled to receive measles, mumps, rubella1. Which of the following findings Should the nurse identify as a contradiction for receiving the vaccine? a. b. upper respiratory infection 2 days ago c. temperature of 37.2 (99 Fahrenheit) d. family history of seizures 56. A nurse is assessing a school-age child cranial nerve function. Which of the following actions should the nurse ask the child to take when assessing the accessory nerve? a. Move their tongue in all directions b. follow a light inthe six cardinal position c. d. show their teeth while smiling 57. A nurse is performing a cranial nerve assessment on a school-age child.Which of the following findings indicates proper function of the child trigeminal nerve? a. The child montanes balance when standing with eyes closed NURSING TEST BANK b. the child correctly identify specific scent c. d. the child exhibits a gag reflex when stimulated with a tongue blade 58. A nurse is providing support to a family whose infant died from suddeninfant death syndrome (Sid's) which of the following actions should the nurse take? a. Discourage the parents from allowing siblings to view the body b. avoid discussing details of the attempt to revive the infant c. provide a follow-up phone call one week following the infant's deathid. 59. A nurse in the emergency department is caring for a child who has a temperature of 39.1 degrees C is (102.4 Fahrenheit) and suspect the diagnosis of bacterial meningitis. Which of the following actions should thenurse take first? Tell me more a. prepare the child for a lumbar puncture b. dim the lights in the child's room (SEIZURE PRECAUTION) c. administering anantipyretic to the child d. Implement droplet precautions forthe child 60. A nurse is caring for an infant who has rotavirus. Which of the followingfindings indicates that the infant is moderately dehydrated? a. capillary refill 1 secondsib. iweight iloss i 7% c. Respiratory rate 28/ minute d. bradycardia 61. A nurse is providing teaching to the guardian of a school-age child whoihas seizure disorder. Which of the following factors should the nurse include as acommon trigger that increases the risk of seizure? a. b. decrease temperature c. lack of sleep d. exposure to second-hand smoke 62. A nurse is reviewing the laboratory results of a preschooler who has gastroenteritis and notes the clients potassium level is 3.2 meq L which ofthe following assessment findings should the nurse expect? a. Hypertension NURSING TEST BANK b. Hyporeflexia c. hyperactive bowel sounds d. Oliguria 63. A nurse is planning care for an adolescent who has sickle cell anemia. Which of the following immunizations should the nurse include in the plan? a. Respiratory sync functional virus (RSV to call) b. Rotavirus c. measles, mumps, and rubella (MMR)i 64. A nurse is planning care for a child who has varicella. Which of thefollowing interventions should the nurse plan to include? a. b. assess the oral cavity for koplik spots c. administer aspirin for fever d. provide the child with a warm blanket 65. A nurse is planning care for a school-age child who has a new diagnosisof Legg calve perthes disease. Which of the following interventions should the nurse include in the plan of care? a. instruct a child to perform weight bearing exercises b. explain to the child that the disease will last 3 to 6 months c. encourage the guardian to keep their child home from school for onemonth d. 66. A nurse is caring for a two-year-old child who has cystic fibrosis and isbeing discharged from the hospital. The nurse should ensure that which ofthe following pieces of equipment is available for the child's home? a. steam vaporizer b. suction machine c. continuous positive airway pressure machineid. ihigh ifrequency ichest icompression 67. 68. A nurse is providing teaching for the parent of a child who has measles.Which of the following information should the nurse include? NURSING TEST BANK a. NURSING TEST BANK b. remove loose crust from the lesions c. give the child aspirin for a fever d. withhold live vaccines for 3 months 69. A nurse is assessing a toddler who has cystic fibrosis. Which of thefollowing findings should the nurse expect? a. Steatorrhea b. Rhinorrhea c. weight gain d. visible peristalsis 70. A nurse is planning to administer diphenhydramine 1.25 mg/kg IV to a school-age child who weighs 55 lb. Available is diphenhydramine 50 mg / ml.How many ml should the nurse administer. Round the answer to the nearest tenth. Use leading zero that applies. Do not use a trailing zero. mL NURSING TEST BANK ATIRNLEADERSHIP PROCTOREDEXAM 2019VERSION 2 ATI Leadership Proctored Exam 1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in thewound care procedure. Which of the following findings indicate wound healing. 1. Erythema on the skin surroundinga client's wound 2. Deep red color onthe center of the clients wound 3. Inflammation noted onthetissue edges of a client's wound 4. Increase in serosanguineous exudate fromthe clients wound 2. A nurse received change of shift report at 0700 for four clients. Which of the following actionsshould the nurse perform first? 1. Obtain a breakfast tray for a client who received a morning dose of insulin aspart 2. Administer pain medication toa client who has rheumatoid arthritis andreceived the lastdose at 0400 3. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900 4. 3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the followingclients should the nurse assign to the newly licensed nurse? 1. A clientwho has multiple sclerosis and ataxia 2. Aclient who has a brain tumor and is admitted for chemotherapy 3. A client who has guillain-barre syndrome and a tracheostomy 4. A client who sustained a concussion and is being monitored for complication 4. A nurse is providingteaching to a client about advance directives. Which of the followingsi tatements by the client indicates an understanding of the teaching? 1. “Once Isign my living will, a family member must co sign it” 2. “Iwill wait until I havea serious health problems to sign my advance directives” 3. “Mydoctor will need to provide approval for the decisions outlines in my living will 4. “My durable power of attorney for healthcare is part of my advance directives” 5. A nurse is chairing a committee about preventinginfant abduction in a new birth care center.Which of the following quality control tasks should the nurse assign to be completed first? 1. Identifythe industry standards for infant safety 2. Evaluatethe selected infant safety system 3. Choose an infant safety system 4. Establish measurement criteria for infant safetysystems 6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to performdysphagia screeningto determine the client's need for areferral to which of the following providers? 1. Physical therapist 2. Respiratorytherapist 3. Speech therapist 4. Occupational therapist 7. A nurse manager is planning to assign carefor four clients on a medical surgical unit. Which ofthefollowing clients should the nurse assign to a LPN? a. An older adult who has lungcancer and has periodic episodes of severe dyspnea b. A middle adult client who has a below the knee amputation and requires a dressingchange c. A youngadult client whois postoperative, receiving morphine via epidural, and reportspruritus d. An adolescent who requires teachingregarding insulin administration 8. 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 thefi ollowing is the priority for the nurse to take? 1. Remind nurses toobtain this information during theadmission process 2. Reinforce the potential consequences of not havinghis information on recordto thenursing staff 3. Meet with nursing staff toreview the policy regarding advance directive 4. Ask nurse who are caringfor client without his information in the medical record toobtain it 9. A nurse is caringfor a group of clients. Which of the following should the nurse see first? 1. A client who is postoperative and has a fever. 2. Aclient whose pressure ulcer has serosanguineous drainage on the dressing 3. A clientwho has diabetes mellitus andis diaphoretic 4. A client who has a fractured hip and reports a pain level of 7 on a scale from 0-10 10. A nurseis receiving change-of-shift report for four clients. Which of the followingclients shouldthe nurse care for first? 1. A client who is 4 hr postoperative following a hernia repair and has pitting edema ofthe right leg 2. Aclient who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea 3. Aclient who has pneumonia and requires a tracheostomy dressing change 4. A client who has a new colostomy and requires discharge teaching 11. A nurse manager discovers there is a conflict between nurses working the day shift and nurseswi orkingon the night shift. Which of the following actions shouldthenurse manager take first? 1. Acknowledge the conflict and encourage the nurses to focus on working as a team 2. Gather information regarding the situation 3. Encouragethe nurses to resolve the conflict autonomously 4. Meet with a committee from each shift to discuss issues related to the conflict 12. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical inan industrial setting. Which of the following actions should the nurse take first? a. Don personal protective equipment b. Irrigate the exposed area with water c. Removethe client’s clothing d. Report the incident to OSHA 13. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client.Which of the following actions should the nurse perform first? 1. Complete an incident report 2. Measure the client’s vital signs 3. Informthe nurse manager 4. Call the provider 14. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls? (SATA) [repeat] a) Awheeled office chair at the client's computer desk b) A raised vinyl seat on thetoilet in the bathroom c) A throw rug covering some cracked floor d) A folding chairwithout arm rests e) Atwo wheeled walker usedto assist the client with ambulation 15. A nurse is assessinga client who has meningitis. Which of the following findings should thenursereport to the provider immediately? a. Decreased level of consciousness b. Generalized rash over trunk c. Increased temperature d. Report of photophobia 16. Aclient who is febrile is admitted to the hospital for treatment of pneumonia. In accordance withithe care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurseto complete a variance report with regard to the care pathway? 1. Antibiotic therapy was initiated 2 hr after implementation of the carepathway. 2. A blood culture was obtained after antibiotic therapy had been initiated 3. An allergy to penicillin required an alternative antibiotic to be prescribed 4. The route of antibiotic therapyon the care pathway was changed from IV to PO 17. A nurse manager is making staffing assignments for the maternal newborn unit. Which of thefollowing clients should the nurse manager assign to a float nurse from the medical-surgical unit? 1. Aclient who is post termand is receiving oxytocin for labor induction 2. Aclient who gave birth to her first child and requires instruction on breastfeeding techniques 3. A client who is 2 days post-operative following acaesarean birth and is having difficultyambulating 4. Aclient who has preeclampsia and is receiving a continuous magnesiumsulfate infusion 18. A nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of methicillin-resistant Staphylococcus aureus (MRSA). Which of the followingmembers of the interprofessional team should the nurse consult? 1. Risk management coordinator 2. Clinical pharmacist 3. Nursing supervisor 4. Infection control nurse 19. A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgeryis not an option. Which ofthefollowing is an appropriate action for the nurse to take? 1. Discuss with the client her concerns regarding the procedure 2. Providethe client withinformation ontreatment options and outcomes 3. Informthe client of the consequences of uterine prolapse and the need for intervention 4. Initiate a mental health consult todetermine the client’s reasons for refusing surgery 20. A nurse in the emergency department is assessing a client who is unconscious following a motor- vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? 1. Delay the surgery until the nurse can obtain informed consent 2. Obtain telephone consent fromthe facility administrator before the surgery. 3. Ask the anesthesiologist to sign the consent. 4. Transport the client to the operating roomwithout verifying informed consent. 21. A nurse is planning to delegate client careassignment. Which of thefollowing tasks should theinurse plan to delegate to an assistive personnel? 1. Performing postmortem care prior to transferring the client to the morgue 2. Advisinga client on self-administration of acetaminophen 3. Teaching a client to perform a finger-stick for testing blood glucose levels 4. Informing a family of a client’s progress in physical therapy 22. A nurse is working on a quality improvement team that is assessing an increase in client fall at thefacility. After problem identification, which of the following actions should the nurse plan toitake first as part of the quality improvement process? 1. Notify staff of the increased fall rate 2. Reviewcurrent literature regarding client falls 3. Implement a fall prevention plan 4. Identifyclients who are at risk of falls 23. A nurse is completingperformance evaluation for an assistive personnel (AP). Which of theifollowing actions by the AP requires intervention by the nurse? 1. The AP uses alcohol handantiseptic after caring for a client who has Clostridiumdifficile. 2. The AP closes the door of a client who is on airborne precautions. 3. The AP Removes cut flowers fromthe room of a client who is in protective environment. 4. The AP wears a mask when a caring for a client who has varicella. 24. A charge nurse notices that the staff nurse are having difficulty using new IV infusion pumps formedication administration. Which of the following is priority action by the charge nurse? a. Assess thestaff nurse’s knowledgedeficit. b. Pair an inexperienced nurse with an experienced nurse. c. Demonstrate use of thepump during medication administration. d. Plan an in-service education program on the unit. 25. A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which of thefollowing tasks should the nurse assign to the AP? 1. Administer the initial bolus feedingto a client who has NG tube 2. Checka client pain level 30min after receiving acetaminophen 3. Collect urinespecimenfor newly admitted client 4. Instruct a client tosplint an abdominal incisions 26. A nurse is assisting with triage duringa mass casualty event. The nurse applies a red tag to aclient. Which of the following actions should the nurse take? 1. Treat the client’s injuries within 30 min 2. Providetreatment for life-threatening injuries 3. Providetreatment for minor injuries 4. Allowthe client to die without further intervention 27. A home health nurse is performing a safety assessment of a client’s home. Which of thefollowing findings should the nurse identify as a safety hazard? a. The client has used tracks to secure the carpet on the stairs b. Theclient’s electrical cord is taped to the floor c. The client’s bedside lamp is plugged in using an extension cord with two prongs d. The client stores cleaning supplies in a locked cabinet above his head 28. Acharge nurse is observing a newly licensed nurse provide care for a client who has Clostridiumdifficile infections. Which of the following actions by the newly licensed nurse indicate an understandingof proper infection control procedures? 1. Applies a mask before entering the client’s room(It’s contact precaution) 2. Removes fresh flowers fromtheclient’s room. 3. Washes her hands withan alcohol-based handrub after caringfor the client.(no, ineffective and must washhands with soap/water) 4. Wears gownwhen caring for client 29. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube.The nurse should assess the client’s need for which of the following supplies to manage tracheostomy at home? (SATA) 1. Pipe cleaners 2. O2 Tank 3. Cottonballs 4. PetroleumJelly 5. Obturator 30. A nurse is caringfor four clients who are scheduled toundergo surgery. Which of the followingclients can give informed consent? 1. An adult client who has alcohol intoxication- NOT FOCUSED 2. An adolescent client who is legally emancipated 3. An older adult client who has questions about theprocedure= having questions meansyi ou dont understand, 4. An adult client who has moderate Alzheimer’s disease.- cant consent if you are notFOCUSED 31. A nurse is discussing the safekeeping of valuables witha client who is scheduled for surgery.Which of thefollowing client statements indicates the need for further teaching? 1. “I can wear my ankle bracelet since i amjust having a local anesthetic: 2. “I can leave my wedding ring on if it is taped in place” 3. “Ishould remove my dentures before the procedure” 4. “Ishould leave my valuables with a family member” 32. A nurse is caring for an older adult client who has Stage III pressure ulcer. The nurse requests aconsultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant? 1. Request the consultation after several wound care treatments aretried 2. Arrange for the wound care nurse specialist to see the client daily to provide therecommended treatments 3. Arrange the consultation for a time when the nurse caring for the client is able to bepresent for the consultation 4. Providethe consultant with subjective opinions and beliefs about the client’s woundcare 33. A nurse is observing an AP administer 0.9% sodiumchloride enema to an adult client. For whichof the following actions by the AP should the nurse intervene? 1. Positions the client on her left side with knees flexed 2. Administers the solution at roomtemp 3. Points tubing in the direction of theumbilicus during insertion 4. Inserts the tubing 8cm(3.1 in) into the rectum 34. A nurse is orienting a newlylicensed nurseabout client confidentiality. Which of the followingstatements by the newly licensed nurse indicates an understanding of the teaching? a. “I should encrypt personal health informationwhen sending emails.” b. “Ican post theclient’s vital signs in the client’s room.” c. “Ican use another nurse’s password as long as I log off after using the computer” d. “Ishould discard personal health information documents in the trash before leaving theunit” 35. A nurse is participating on a committee that is considering the creation of a policy that will allowthe nurses to remove chest tubes. Which of the following is an appropriate resource for the nurseito consult in planning for this policy? (2016 practice) 1. ANA Standards of Practice 2. ANA Code of Ethics 3. State Nurse Practice Act 4. Institute of medicine 36. A charge nurse observe a licensed practical nurse tell a client that she will return with a medication to help relieve the client’s nausea. The LPN does not return with the medication. Theicharge nurse should reinforce which of the following ethical principles withthe LPN? a. Veracity b. Justice c. Fidelity d. Nonmaleficence 37. A nurseadministrator is usingbenchmarking as control criteria whilereviewing current policiesand procedures. Which of the following actions should the nurse take? 1. Use root cause analysis to identify gaps in meetingstandards- root cause analysis is doneif the benchmark is not met 2. Establish work initiatives topromote a positive environment 3. Compare practices withinthe facility against other high-performing facilities 4. Determine how current practice will affect future performance withinthefacility 38. A nurse enters a client’s roomand identifies that the client is receiving too much IV fluid becausethe IV pump is not working properly. Which of the following actions should the nurse take first? 1. Placea faulty equipment tagon the pump 2. Notifythe provider 3. Auscultate the client’s lungs 4. Complete an incident report 39. Aclient scheduled for a tubal ligation procedure starts to cryas she is wheeled into the surgicalsuite. Which of the following nursing statements is an appropriate nursing response? 1. “It’s not too late to cancel the surgery if youwant to” 2. “Why did you make the decision to have this procedure?” 3. “This won’t take longand it will be over before you know it” 4. “You shouldn’t be worried because the procedure is very safe” 40. Afacility infection control nurse is reviewingthereports of a group of clients. Which of thefollowing infections should the nurse report to the public health department? 1. Lyme disease 2. Bacterial conjunctivitis 3. Health care-acquired pneumonia 4. MRSA 41. A nurse on a surgical unit is preparingto transfer a client to a rehabilitation facility. Which of thefollowing information should the nurse include in the change-of-shift report? 1. The steps to follow when providing wound care 2. Theclient’s preferred time for bathing 3. Thebelief that theclient has a difficult relationship with his son 4. The time the client received his last dose of pain medication 42. A nurse receives a new prescription over thetelephone froma client’s provider. Which of thefi ollowing actions should the nurse take first? 1. Write down the complete prescription 2. Read back the prescription to the provider 3. Document the prescription as a telephone prescription in the medical record 4. Ensurethat the provider signs the prescription 43. A charge nurse witnessed an assistive personnel failing to follow facility protocol when discardingcontaminated linens. Which of the following actions should the nurse take first? 1. Discuss the issue with the AP 2. Notifythe unit manager about the incident 3. Reinforce facility protocols at the next staff meeting 4. Alert the infectioncontrol department 44. A nurse is planningcarefor a client who is disoriented and has a history of wandering. Which ofthefollowing actions should the nurse include in the plan? 1. Raiseall four side rails on the client’s bed 2. Remove the clock and calendar fromthe client’s room 3. Obtaina prescription for a sedative for the client 4. Provide distractions for the client during the day 45. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the followingactions should the nurse take? 1. Initiate contact precautions (standard) 2. Report the infection to the local health department 3. Apply an antiviral creamto lesions 4. Instruct the client to usecondoms until the treatment is completed(NO, not 100%preventable) 46. A nurse is teachinga class of newly licensed nurses about evidence-based practices. The nurseishould include which of the following as the first step in evidence-based practice? 1. Applyresearch to client care practice 2. Develop a clinical question 3. Criticallyassess the evidence 4. Collect evidence froma variety of sources 47. A nurse assumes the leading role on the hazardous materials team immediately following a chemical mass casualtyincident inthe community. As clients arrive at the designed triage areaoutside the hospital, which of thefollowing actions should the nurse take? 1. Placeshower caps over theclient's’ hair 2. Removecontaminated clothing 3. Scrubtheclient’s skin with betadine solution 4. Admit the injured clients topositive-pressure rooms 48. Acase manager is reviewing documentation on several clients and notes a progress report thatfalsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? a. Libel b. Negligence c. Battery d. Slander 49. A nurse is preparing to complete morningassignments on several assigned clients. Which of theifollowing clients should the nurse plan to assess first? 1. Aclient who had a bladder scan that indicated 250 mL of urine in the bladder 2. Aclient who is 3 days postoperative and who’s dressing has serosanguinous drainage 3. Aclient who has diabetes and an early morning blood glucose of 220 mg/dL 4. A client who has a nasogastric tube to intermittent suction and reports nausea 50. Acharge nurse overhears a staff nurse discussing a client’s diagnosis in the cafeteria. Which ofthefollowing responses should the charge nurse make? 1. “Please stop discussing the client in a public area” 2. “Do you understand the HIPAA regulations?” 3. “Weshould discuss your concerns with the client’s care team” 4. “Iwill notifythe client’s provider about this breach of confidentiality 51. A nurse preceptor is observing a newly hired nurse performa sterile dressingchange. Which ofthefollowing actions should the nurse preceptor identify as maintaining sterile technique? 1. Places sterile gauze 1.3cm(0.5 in) away fromthe edge of a sterile drape 2. Uses sterile forceps to pack sterile gauze into thewound 3. Sets up the sterile field 30 min prior to performing the dressing change 4. Uses a sterile-gloved hand to adjust theback of the sterile gown. 52. A nurse working in a long-term care facility is assessing an older adult client who has been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the followingactions should the nurse take? 1. Placethe client in a negative-pressure airflow room 2. Performhand hygiene withalcohol based hand sanitizer. 3. Cleanthe equipment in the client’s room with bleach. 4. Initiate droplet precautions for the client. 53. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is havingtrouble focusing and has difficulty completing care for his assigned clients. Which of theifollowing interventions is appropriate? 1. Advise himto complete the less time-consuming tasks first 2. Recommend that he take time to plan at the beginning of his shifts 3. Offer to provide carefor his clients while he takes a break 4. Ask other staff members to take over some of his tasks 54. A nurse is planningdischarge for a client who has lung resection. The nurse initiates a referral fora social worker. Which of the following assessment data supports this referral? 1. The client needs to have someone bring O2 tanks and equipment to her home 2. Theclient needs to haverange-of-motion exercises toassist with ambulation 3. The client needs to arrange financial resources to purchase equipment 4. The client needs to have someone come in to help her batheat home 55. A nurse initiates a referral to an occupationtherapist for a client who has rheumatoid arthritis.Which of the following assessment findings supports the need for this referral? 1. Theclient reports pain when chewing solid foods. 2. The client expresses the desiretojoin a support group. 3. The client requires assistance with completing oral hygiene 4. Theclient has difficultyambulating with a walker 56. A nurse is caringfor a client who has anorexia nervosa. Which of the following interdisciplinaryteam members should be consulted in regard to this client’s care? (SATA) 1. Nutritional therapists 2. Case Manager 3. Mental Healthcounselor 4. Occupational therapist 5. Physical therapist 57. A nurse is prioritizing careafter a receiving change-of-shift report on four clients. Which of theifollowing clients should the nurse assess first? a. Aclient who reports a headache with sensitivity to light. b. Aclient who reports feeling lightheaded when he stands up froma lying position c. A client who reports indigestion and pain in her jaw d. Aclient who reports an urge to void but has not urinated during the prior shift 58. A nurse on an acute mental health unit is assessingfour clients. Which of thefollowing clients isthe highest priority? 1. Aclient who has depressive disorder and has poor personal hygiene 2. Aclient who has dementia and exhibits aphasia 3. A client who has bipolar disorder and displays constant pacing – (Can lead tophysical exhaustion and death) 4. Aclient who has schizophrenia and uses neologisms 59. A nurse is planningcare for a group of clients. Which of the following action should the nursetake first? 1. Obtaina breakfast tray for a client whose total parenteral nutrition was discontinued 4 hrsiago. 2. Auscultatethe bowel sounds of a client who has not had bowel movement after taking alaxative 12hr ago. 3. Provide instruction to the caregiver of a client who has dementia and new diagnosis ofdiabetes mellitus. 4. Check a client who has a leg cast and reports a new onset of pain. 60. A nurse on a med surg unit is caring for a client who asks about advance directives and states thathe wants to appoint a health care proxy. Which of the following responses should the nurse make? 1. “You must choose a member of your family toserve as a your health care proxy.” 2. “A health care proxy can make decisions for youwhen you are unable to do so.” 3. “You should appoint a health care proxy before undergoing an invasive procedure.” 4. “It is necessary for an attorney to approve your health care proxy.” 61. A nursein a rehabilitation facility is administering medications to a client who was admittediearlier that day. The client refuses two of the medications, stating, “I’ve never taken these before.” Which of the following actions should the nurse take