ATI Leadership Retake NCLEX Assignment 2021

13. The nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying of the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? My Answer: 3 - The client was found lying in the floor Correct Answer: 3 14. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? My Answer: 3 - Transport the victim to the operating room for surgery Correct Answer: 3 15 The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? My Answer: 4 - Contact the nursing supervisor to update information regarding the call Correct Answer: 1 - Reassess the client Rationale: After a client’s fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. 16 The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? My Answer: 4 - Identify tasks that can be performed safely in the ICU Correct Answer: 4 17. The nurse who works on the night shift enters the medication room and finds a co-worker which a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? My Answer: 3 - Call the nursing supervisor Correct Answer: 3 18. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? My Answer: 4 - I will call the nursing supervisor to seek assistance regarding your request Correct Answer: 4 19. The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client’s medical record to correct the error. The nurse should take which action to correct the error? My Answer: 4 - Drawing one line through the error, initialing and dating, and then documenting the correct information Correct Answer: 4 20. Which identifies accurate nursing documentations notations? My Answers: 2, 5 2. Abdominal wound dressing is dry and intact without drainage 5. The client’s left lower medial leg wound is 3cm in length without redness, drainage, or edema Correct Answers: 1, 2, 5 1. The client slept through the night 2. Abdominal wound dressing is dry and intact without drainage 5. The client’s left lower medial leg wound is 3cm in length without redness, drainage, or edema Rationale: Factual documentation contains descriptive, objective information about what the nurse sees, hears feels, or smells.