ne
sh
RN ATI LEADERSHIP ONLINE PRACTICE 2023 B
ne
QUESTIONS AND CORRECT DETAILED
la
tz
ANSWERS WITH RATIONALES A+ GRADED
sh
Sp
ne
la
Which of the following findings should the nurse identify require follow-up by the
provider? Select the 6 findings that require immediate follow-up.
sh
Sp
Exhibit 1:
ne
Day 1, 1715:
Client is 6 hr postoperative following abdominal surgery. Client is resting and easily
la
awakened. Alert and oriented to person, place, and time. Incision has moderate amount
tz
of serous sanguineous draining on dressing. Abdominal dressing is intact. States pain
sh
Sp
level is a 4 on a 0 to 10 pain scale. Bowel sounds are normoactive. Client tolerating sips
ne
of water. Urinary output 320 mL in last 4hr.
Day 1, 2030:
la
Nurse enters room client's room. Client is restless and short of breath. Client rates pain
sh
as an 8 on a scale of 0 to 10, saying,
Sp
"My abdomen hurts so bad." Nurse notes dressing site has large amounts of bright red
ne
blood.
la
tz
-Blood pressure
sh
-Bowel sounds
Sp
-Pain level
ne
-Respiratory rate
la
-Urinary output
-Heart rate
sh
-Orientation status
Sp
ne
-Oxygen saturation - Answer-When analyzing cues, the nurse should identify that an
increase in heart rate, respiratory rate, a pain level of 8 on a scale of 0 to 10, a large
la
amount of bright red blood on the client's abdominal dressing, along with a decrease in
tz
blood pressure and oxygenation saturation are manifestations of hemorrhage.
sh
Sp
Therefore, the nurse should notify the client's provider of these findings immediately.
ne
A charge nurse is reviewing the plan of care for a client who has active herpes simplex
la
lesions. Which of the following interventions is appropriate for the plan of care?
sh
Sp
a. Admit the client to a private room with negative-pressure airflow.
ne
b. Wear a gown and gloves when caring for the client.
c. Have the client wear a mask during transport.
a
tz
d. Wear a face mask and eye protection when caring for the client. - Answer-b. Wear a
l
sh
gown and gloves when caring for the client.
Sp
ne
The nurse should use contact precautions when caring for clients who have an infection
la
from herpes simplex. Barriers with gloves and gowns are mandatory.
sh
Sp
la
Sp
, ne
sh
ne
A nurse is caring for several clients. Which of the following actions should the nurse
la
take to maintain client confidentiality?
tz
sh
a. Tell a client's partner that the client's laboratory tests cannot be disclosed without
Sp
permission.
ne
b. Ask the assistive personnel (AP) to refer to clients by room number in public areas.
la
c. Explain to a nursing student that verbal permission must be obtained before using a
client's name in school assignments.
sh
Sp
d. Share information about a client with
ne
members after personal identification has been provided. - Answer-a. Tell a client's
partner that the client's laboratory tests cannot be disclosed without permission.
la
tz
This action by the nurse will maintain client confidentiality. Providing a client's partner
sh
Sp
with laboratory results without permission is unauthorized disclosure of confidential
ne
information.
la
A charge nurse is managing conflict with a staff nurse who does not agree with the
sh
client care assignment. Which of the following statements example of using the conflict
Sp
resolution strategy known as smoothing?
ne
la
a. "Would you accept the assignment if we reassign your client who has total care
tz
needs and assign another client who can provide more self-care?"
sh
b. "Tell me what changes we need to make so that you'll feel comfortable with the
Sp
assignment."
ne
c. "I didn't mean to make you feel overwhelmed. Why don't you look over the
la
assignments with me and suggest changes?"
d. "You always complete your work on time and do a great job. I believe you can handle
sh
Sp
the assignment well." - Answer-d. "You always complete your work on time and do a
ne
great job. I believe you can handle the assignment well."
la
The charge nurse is using smoothing as a conflict resolution strategy by complimenting
tz
or focusing on shared ideas to reduce the emotional component of the conflict.
sh
Sp
ne
A nurse manager is planning daily work and activities for the unit. Which of the following
actions is the nurse manager's priority?
la
sh
a. Assign client care to staff.
Sp
b. Coordinate staff breaks.
ne
c. Organize daily meetings using an appointment book.
d. Review long-term goals of the unit. - Answer-a. Assign client care to staff.
a
tz
l
sh
When using the urgent vs nonurgent approach to client care, the nurse determines that
Sp
the priority action is to assign client care to staff. This ensures continuity of care and
ne
that clients receive prescribed treatments in a timely manner.
la
sh
Sp
la
Sp
, ne
sh
A nurse is caring for a school-age client who is seeking treatment for a laceration to the
ne
right forearm that occurred during soccer practice. The client was transported to the
la
emergency department by a friend's parent and the soccer coach. The nurse should
tz
ensure that informed consent is given by which of the following people?
sh
Sp
ne
a. The client
b. The friend's parent
la
c. The client's guardian
d. The soccer coach - Answer-c. The client's guardian
sh
Sp
ne
The parent or legal guardian is authorized to give consent for the client.
la
A client is considering having a tubal ligation and reports being uncertain about if it is
tz
the right thing to do. Which of the following actions should the nurse take?
sh
Sp
ne
a. Provide information about alternate birth control methods.
b. Ask if the client has discussed the decision with their partner.
la
c. Emphasize the benefits of having the procedure.
sh
d. Discuss the client's feelings about the procedure. - Answer-d. Discuss the client's
Sp
feelings about the procedure.
ne
la
The nurse should encourage the client to discuss any feelings or concerns about the
tz
procedure.
sh
Sp
An RN is assigning tasks to team members. Which of the following tasks is appropriate
ne
to delegate to a licensed practical nurse (LPN)?
la
a. Complete a client's admission assessment.
sh
Sp
b. Titrate the flow of diltiazem IV for a client who is in a hypertensive crisis.
ne
c. Develop a teaching plan for a client who was recently diagnosed with diabetes
mellitus.
la
d. Suction a client who has a chronic tracheostomy. - Answer-d. Suction a client who
tz
has a chronic tracheostomy. sh
Sp
ne
Suctioning a client who has a tracheostomy is within the LP's scope of practice. The RN
should determine the LPN's competency and the stability of the client when considering
la
delegation of this task.
sh
Sp
A nurse walks into the nurses' station and sees several staff members looking at the
ne
electronic medical record for a celebrity client on another unit. Which of the following
actions should the nurse take first?
a
tz
l
sh
a. Remind the staff members that this is a breach of confidentiality.
Sp
b. Discuss the issue with the nurse manager.
ne
c. Request that an administrative restriction be placed on the client's record access.
la
sh
Sp
la
Sp
sh
RN ATI LEADERSHIP ONLINE PRACTICE 2023 B
ne
QUESTIONS AND CORRECT DETAILED
la
tz
ANSWERS WITH RATIONALES A+ GRADED
sh
Sp
ne
la
Which of the following findings should the nurse identify require follow-up by the
provider? Select the 6 findings that require immediate follow-up.
sh
Sp
Exhibit 1:
ne
Day 1, 1715:
Client is 6 hr postoperative following abdominal surgery. Client is resting and easily
la
awakened. Alert and oriented to person, place, and time. Incision has moderate amount
tz
of serous sanguineous draining on dressing. Abdominal dressing is intact. States pain
sh
Sp
level is a 4 on a 0 to 10 pain scale. Bowel sounds are normoactive. Client tolerating sips
ne
of water. Urinary output 320 mL in last 4hr.
Day 1, 2030:
la
Nurse enters room client's room. Client is restless and short of breath. Client rates pain
sh
as an 8 on a scale of 0 to 10, saying,
Sp
"My abdomen hurts so bad." Nurse notes dressing site has large amounts of bright red
ne
blood.
la
tz
-Blood pressure
sh
-Bowel sounds
Sp
-Pain level
ne
-Respiratory rate
la
-Urinary output
-Heart rate
sh
-Orientation status
Sp
ne
-Oxygen saturation - Answer-When analyzing cues, the nurse should identify that an
increase in heart rate, respiratory rate, a pain level of 8 on a scale of 0 to 10, a large
la
amount of bright red blood on the client's abdominal dressing, along with a decrease in
tz
blood pressure and oxygenation saturation are manifestations of hemorrhage.
sh
Sp
Therefore, the nurse should notify the client's provider of these findings immediately.
ne
A charge nurse is reviewing the plan of care for a client who has active herpes simplex
la
lesions. Which of the following interventions is appropriate for the plan of care?
sh
Sp
a. Admit the client to a private room with negative-pressure airflow.
ne
b. Wear a gown and gloves when caring for the client.
c. Have the client wear a mask during transport.
a
tz
d. Wear a face mask and eye protection when caring for the client. - Answer-b. Wear a
l
sh
gown and gloves when caring for the client.
Sp
ne
The nurse should use contact precautions when caring for clients who have an infection
la
from herpes simplex. Barriers with gloves and gowns are mandatory.
sh
Sp
la
Sp
, ne
sh
ne
A nurse is caring for several clients. Which of the following actions should the nurse
la
take to maintain client confidentiality?
tz
sh
a. Tell a client's partner that the client's laboratory tests cannot be disclosed without
Sp
permission.
ne
b. Ask the assistive personnel (AP) to refer to clients by room number in public areas.
la
c. Explain to a nursing student that verbal permission must be obtained before using a
client's name in school assignments.
sh
Sp
d. Share information about a client with
ne
members after personal identification has been provided. - Answer-a. Tell a client's
partner that the client's laboratory tests cannot be disclosed without permission.
la
tz
This action by the nurse will maintain client confidentiality. Providing a client's partner
sh
Sp
with laboratory results without permission is unauthorized disclosure of confidential
ne
information.
la
A charge nurse is managing conflict with a staff nurse who does not agree with the
sh
client care assignment. Which of the following statements example of using the conflict
Sp
resolution strategy known as smoothing?
ne
la
a. "Would you accept the assignment if we reassign your client who has total care
tz
needs and assign another client who can provide more self-care?"
sh
b. "Tell me what changes we need to make so that you'll feel comfortable with the
Sp
assignment."
ne
c. "I didn't mean to make you feel overwhelmed. Why don't you look over the
la
assignments with me and suggest changes?"
d. "You always complete your work on time and do a great job. I believe you can handle
sh
Sp
the assignment well." - Answer-d. "You always complete your work on time and do a
ne
great job. I believe you can handle the assignment well."
la
The charge nurse is using smoothing as a conflict resolution strategy by complimenting
tz
or focusing on shared ideas to reduce the emotional component of the conflict.
sh
Sp
ne
A nurse manager is planning daily work and activities for the unit. Which of the following
actions is the nurse manager's priority?
la
sh
a. Assign client care to staff.
Sp
b. Coordinate staff breaks.
ne
c. Organize daily meetings using an appointment book.
d. Review long-term goals of the unit. - Answer-a. Assign client care to staff.
a
tz
l
sh
When using the urgent vs nonurgent approach to client care, the nurse determines that
Sp
the priority action is to assign client care to staff. This ensures continuity of care and
ne
that clients receive prescribed treatments in a timely manner.
la
sh
Sp
la
Sp
, ne
sh
A nurse is caring for a school-age client who is seeking treatment for a laceration to the
ne
right forearm that occurred during soccer practice. The client was transported to the
la
emergency department by a friend's parent and the soccer coach. The nurse should
tz
ensure that informed consent is given by which of the following people?
sh
Sp
ne
a. The client
b. The friend's parent
la
c. The client's guardian
d. The soccer coach - Answer-c. The client's guardian
sh
Sp
ne
The parent or legal guardian is authorized to give consent for the client.
la
A client is considering having a tubal ligation and reports being uncertain about if it is
tz
the right thing to do. Which of the following actions should the nurse take?
sh
Sp
ne
a. Provide information about alternate birth control methods.
b. Ask if the client has discussed the decision with their partner.
la
c. Emphasize the benefits of having the procedure.
sh
d. Discuss the client's feelings about the procedure. - Answer-d. Discuss the client's
Sp
feelings about the procedure.
ne
la
The nurse should encourage the client to discuss any feelings or concerns about the
tz
procedure.
sh
Sp
An RN is assigning tasks to team members. Which of the following tasks is appropriate
ne
to delegate to a licensed practical nurse (LPN)?
la
a. Complete a client's admission assessment.
sh
Sp
b. Titrate the flow of diltiazem IV for a client who is in a hypertensive crisis.
ne
c. Develop a teaching plan for a client who was recently diagnosed with diabetes
mellitus.
la
d. Suction a client who has a chronic tracheostomy. - Answer-d. Suction a client who
tz
has a chronic tracheostomy. sh
Sp
ne
Suctioning a client who has a tracheostomy is within the LP's scope of practice. The RN
should determine the LPN's competency and the stability of the client when considering
la
delegation of this task.
sh
Sp
A nurse walks into the nurses' station and sees several staff members looking at the
ne
electronic medical record for a celebrity client on another unit. Which of the following
actions should the nurse take first?
a
tz
l
sh
a. Remind the staff members that this is a breach of confidentiality.
Sp
b. Discuss the issue with the nurse manager.
ne
c. Request that an administrative restriction be placed on the client's record access.
la
sh
Sp
la
Sp
