ATI Leadership| NURS 420 | Latest
Exam 2021
EXAM
1. An RN is delegating tasks to an LPN. Which task
is most appropriate?
A. Initiate a blood transfusion.
B. Perform an initial postoperative assessment.
C. Administer a routine subcutaneous insulin injection.
D. Develop a client’s plan of care.
Answer: C
Rationale: LPNs can administer routine subcutaneous
medications, including insulin, for stable clients. Initial
assessments, blood products, and care plan development require
RN judgment.
2. A charge nurse is making assignments on a medical-surgical
unit. Which client should be assigned to the most experienced
RN?
A. Client with diabetes requesting diet teaching.
B. Client with hip fracture needing assistance with a bedpan.
C. Client with new-onset aphasia and facial droop.
D. Client with chronic COPD and stable vital signs.
Answer: C
Rationale: New neurologic deficits (aphasia, facial droop) suggest
,a possible stroke, requiring rapid assessment and intervention.
This unstable client needs the highest level of nursing expertise.
3. Which of the following tasks can the nurse delegate to an
assistive personnel (AP)?
A. Evaluate a client’s ability to swallow after a stroke.
B. Empty a client’s indwelling urinary catheter drainage bag.
C. Interpret a client’s cardiac telemetry rhythm.
D. Teach a client how to use an incentive spirometer.
Answer: B
Rationale: Emptying a urinary drainage bag is a standard,
non-invasive, and routine task that falls within AP scope of
practice. Evaluation, interpretation, and teaching require licensed
nursing judgment.
4. An RN is supervising a newly licensed nurse who is performing
sterile wound care. Which action requires the RN to intervene?
A. The nurse opens the sterile pack by unfolding the top flap away
from the body.
B. The nurse places sterile items within the 1-inch border of the
sterile field.
C. The nurse holds the sterile solution bottle with the label facing
the palm.
D. The nurse drops a sterile gauze pad directly onto the center of
the field.
Answer: B
Rationale: The 1-inch border around the edge of a sterile field is
considered unsterile. The nurse should place items at least 1 inch
inside the border, not within it.
,5. A charge nurse is delegating vital signs to an AP. Which
instruction is most appropriate?
A. “Take vital signs on all clients, and let me know if anything is
abnormal.”
B. “Please obtain oral temperatures on everyone except the client
in Room 4, who needs a tympanic reading.”
C. “You are responsible for deciding how often vital signs are
needed.”
D. “I’ll show you once, then you can figure out the rest.”
Answer: B
Rationale: Effective delegation includes clear, specific, and
complete instructions. This answer identifies the task, the method,
and the exception. The delegating RN retains responsibility for
frequency and interpretation.
6. Which of the following is an appropriate task for an LPN?
A. Perform the initial admission assessment on a client with
pneumonia.
B. Administer IV push morphine to a postoperative client in severe
pain.
C. Reinforce teaching about a low-sodium diet previously taught
by the RN.
D. Write the nursing diagnosis for a client’s plan of care.
Answer: C
Rationale: Reinforcing existing teaching is within LPN scope.
Initial assessment, IV push opioids, and writing nursing diagnoses
are RN responsibilities.
7. A nurse manager is observing a staff nurse delegate tasks.
Which action indicates ineffective delegation?
, A. The nurse checks the AP’s vital sign readings before giving a
medication.
B. The nurse tells the AP, “Ambulate Mr. Jones whenever he asks.”
C. The nurse asks the LPN to obtain a blood glucose reading.
D. The nurse assigns a complex dressing change to an
experienced LPN.
Answer: B
Rationale: Delegation must be specific, including what, when, and
how. Vague instructions like “whenever he asks” can lead to
missed or delayed care. The nurse should specify frequency or
time.
8. A client refuses to allow an AP to take his blood pressure. The
AP reports this to the RN. What is the RN’s best response?
A. “Tell the client it is hospital policy.”
B. “I will talk to the client and try to find out why he is refusing.”
C. “You should try again later when he is asleep.”
D. “Document that the client is non-compliant.”
Answer: B
Rationale: The RN must assess the reason for refusal. Clients have
the right to refuse care, but the nurse should explore concerns,
provide education, and respect autonomy.
9. A charge nurse is assigning rooms for four new admissions.
Which client should be placed in a private room?
A. Client with a hip fracture.
B. Client with pneumonia.
C. Client with Clostridioides difficile (C. diff) infection.
D. Client with cellulitis.
Exam 2021
EXAM
1. An RN is delegating tasks to an LPN. Which task
is most appropriate?
A. Initiate a blood transfusion.
B. Perform an initial postoperative assessment.
C. Administer a routine subcutaneous insulin injection.
D. Develop a client’s plan of care.
Answer: C
Rationale: LPNs can administer routine subcutaneous
medications, including insulin, for stable clients. Initial
assessments, blood products, and care plan development require
RN judgment.
2. A charge nurse is making assignments on a medical-surgical
unit. Which client should be assigned to the most experienced
RN?
A. Client with diabetes requesting diet teaching.
B. Client with hip fracture needing assistance with a bedpan.
C. Client with new-onset aphasia and facial droop.
D. Client with chronic COPD and stable vital signs.
Answer: C
Rationale: New neurologic deficits (aphasia, facial droop) suggest
,a possible stroke, requiring rapid assessment and intervention.
This unstable client needs the highest level of nursing expertise.
3. Which of the following tasks can the nurse delegate to an
assistive personnel (AP)?
A. Evaluate a client’s ability to swallow after a stroke.
B. Empty a client’s indwelling urinary catheter drainage bag.
C. Interpret a client’s cardiac telemetry rhythm.
D. Teach a client how to use an incentive spirometer.
Answer: B
Rationale: Emptying a urinary drainage bag is a standard,
non-invasive, and routine task that falls within AP scope of
practice. Evaluation, interpretation, and teaching require licensed
nursing judgment.
4. An RN is supervising a newly licensed nurse who is performing
sterile wound care. Which action requires the RN to intervene?
A. The nurse opens the sterile pack by unfolding the top flap away
from the body.
B. The nurse places sterile items within the 1-inch border of the
sterile field.
C. The nurse holds the sterile solution bottle with the label facing
the palm.
D. The nurse drops a sterile gauze pad directly onto the center of
the field.
Answer: B
Rationale: The 1-inch border around the edge of a sterile field is
considered unsterile. The nurse should place items at least 1 inch
inside the border, not within it.
,5. A charge nurse is delegating vital signs to an AP. Which
instruction is most appropriate?
A. “Take vital signs on all clients, and let me know if anything is
abnormal.”
B. “Please obtain oral temperatures on everyone except the client
in Room 4, who needs a tympanic reading.”
C. “You are responsible for deciding how often vital signs are
needed.”
D. “I’ll show you once, then you can figure out the rest.”
Answer: B
Rationale: Effective delegation includes clear, specific, and
complete instructions. This answer identifies the task, the method,
and the exception. The delegating RN retains responsibility for
frequency and interpretation.
6. Which of the following is an appropriate task for an LPN?
A. Perform the initial admission assessment on a client with
pneumonia.
B. Administer IV push morphine to a postoperative client in severe
pain.
C. Reinforce teaching about a low-sodium diet previously taught
by the RN.
D. Write the nursing diagnosis for a client’s plan of care.
Answer: C
Rationale: Reinforcing existing teaching is within LPN scope.
Initial assessment, IV push opioids, and writing nursing diagnoses
are RN responsibilities.
7. A nurse manager is observing a staff nurse delegate tasks.
Which action indicates ineffective delegation?
, A. The nurse checks the AP’s vital sign readings before giving a
medication.
B. The nurse tells the AP, “Ambulate Mr. Jones whenever he asks.”
C. The nurse asks the LPN to obtain a blood glucose reading.
D. The nurse assigns a complex dressing change to an
experienced LPN.
Answer: B
Rationale: Delegation must be specific, including what, when, and
how. Vague instructions like “whenever he asks” can lead to
missed or delayed care. The nurse should specify frequency or
time.
8. A client refuses to allow an AP to take his blood pressure. The
AP reports this to the RN. What is the RN’s best response?
A. “Tell the client it is hospital policy.”
B. “I will talk to the client and try to find out why he is refusing.”
C. “You should try again later when he is asleep.”
D. “Document that the client is non-compliant.”
Answer: B
Rationale: The RN must assess the reason for refusal. Clients have
the right to refuse care, but the nurse should explore concerns,
provide education, and respect autonomy.
9. A charge nurse is assigning rooms for four new admissions.
Which client should be placed in a private room?
A. Client with a hip fracture.
B. Client with pneumonia.
C. Client with Clostridioides difficile (C. diff) infection.
D. Client with cellulitis.
