LEADERSHIP ATI TEST BANK_2020 {UPDATED 2022/2023} - South University | LEADERSHIP ATI 2022/2023 - A Grade

LEADERSHIP ATI 2022/2023 1. A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) D. Rescue the clients. A. Pull the fire alarm. B. Confine the fire. C. Extinguish the fire. 2. A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication? A. Utilitarianism Rationale: Utilitarianism refers to actions that are right when they contribute to the greatest good. B. Nonmaleficence Rationale: Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care workers refrain from intentionally inflicting harm to clients. C. Fidelity Rationale: Fidelity is the duty to keep one's promises or word. It refers to the obligation to be faithful to the agreements, commitments, and responsibilities that one has made to oneself and others. D. Veracity Rationale: Veracity is the duty to tell the truth. It means that one does not intentionally deceive or mislead clients. 3. A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? A. "I need to talk to you about unit expectations regarding delegating and completing tasks." Rationale: This statement opens the conversation in a nonthreatening way. The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual. B. "Several staff members have commented that you don't do your fair share of the work." Rationale: This statement is accusatory. C. "If you don't do your share of the work, I will have to inform the nurse manager." Rationale: This statement is punitive. D. "You have been very inconsiderate of others by not completing your share of the work." Rationale: This statement is punitive. 4. A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon’s medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles? A. Utility Rationale: Utility is the ethical principle that the good of many people outweighs the good of one person. B. Paternalism Rationale: Paternalism is the belief that one individual has the right to make decisions for another. It negates the client’s right to autonomy. C. Justice Rationale: Justice is the ethical principled based on the belief that everyone should be treated fairly. D. Nonmaleficence Rationale: The nurse is obligated to protect the client’s confidential information. A breach of confidentiality can place the client at risk of harm. Nonmaleficence is the ethical duty to prevent harm to the client. 5. When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation? A. The AP's ability to prioritize Rationale: Although the nurse could determine the AP’s ability to prioritize, this is not one of the rights of delegation. B. The AP has the knowledge and skill to perform the task Rationale: The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task. C. The AP's rapport with clients Rationale: Although a positive rapport with clients is important, this is not one of the five rights of delegation. D. The AP’s ability to complete the task without assistance Rationale: The nurse does not relinquish accountability for supervising the AP; therefore, this is not one of the five rights of delegation. 6. While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? A. Complete an incident report. Rationale: The nurse should complete an incident report; however, there is another action the nurse should take first. B. Request the risk manager obtain consent for HIV testing from the client. Rationale: Although it is important that the client’s HIV status is determined, there is another action the nurse should take first. C. Wash the site of injury with soap and water. Rationale: The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission. D. Consent to postexposure treatment with antiretroviral medications. Rationale: Although treatment with antiretroviral medications should be started within 1 to 2 hr after a needle stick injury and be continued for 28 days if the client’s HIV status is positive, there is another action the nurse should take first. 7. A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification? A. "I can change who I designate as my health care proxy at any time." Rationale: This is a correct statement regarding a health care proxy. B. "If I become incapacitated, end-of-life choices will be made by my proxy." Rationale: This is a correct statement regarding a health care proxy. C. "I have to choose a family member as my health proxy." Rationale: The client should choose someone he trusts and knows about his wishes for day-to-day and end-of-life care. It can be a family member, but it does not have to be a family member. D. "The health care proxy does not go into effect until I am incapable of making decisions." Rationale: This is a correct statement regarding a health care proxy. 8. A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first? A. Provide an inservice on medication administration to all the nurses. Rationale: A recommendation for staff education may be indicated, but this does not assist the committee to identify factors that lead to medication errors. B. Require staff nurses to demonstrate competency by passing a medication administration examination. Rationale: Ensuring competency in medication administration may be indicated, but this does not assist the committee to identify factors that lead to medication errors. C. Review the events leading up to each medication administration error. Rationale: After a sentinel event, the first step the committee should plan to take is to use root cause analysis to identify the underlying cause or causes that led to the medication errors. D. Develop a quality improvement program for nurses involved in medication administration errors. Rationale: Although development of a quality improvement program for nurses involved in medication errors may be indicated, this does not assist the committee to identify factors that lead to medication errors. 9. A charge nurse has access to the facility’s electronic client records. It is appropriate for the charge nurse to share her personal password with whom? A. The nurse manager Rationale: A nurse manager authorized to have access to a computer will have a personal password. B. No one Rationale: Computer passwords cannot be shared with others for any reason. Any facility employee authorized to have access to the database on a computer will have a personal password. C. A nursing student who is completing a preceptorship on the unit Rationale: A nursing student who is authorized to have access to the database on a computer will have a personal password. D. The unit clerk Rationale: A unit clerk authorized to have access to a computer will have a personal password. 10. A nurse on a medical-surgical unit is reconciling a newly admitted client’s medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information? A. The American Hospital Association requires accredited facilities to have protocols in place requiring medication reconciliation. Rationale: The Joint Commission requires accredited facilities to have protocols in place requiring medication reconciliation. B. The purpose of medication reconciliation is to prevent adverse medication reactions. Rationale: Medication reconciliation includes reviewing an accurate list of all medications the client is taking and comparing that list to new medications the provider has prescribed. This action decreases the risk of medication interactions and adverse outcomes. C. The nurse who performs medication reconciliation is demonstrating the ethical principal of veracity. Rationale: This action by the nurse does not demonstrate the ethical principal veracity, which means telling the truth. The nurse who performs medication reconciliation is demonstrating the ethical principle beneficence, which means the nurse takes action to promote good, and nonmaleficence, which means the nurse takes action to prevent harm. D. The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility. Rationale: The International Council of Nurses Code of Ethics stipulates that nurses have a responsibility to promote health and prevent illness, but it does not mandate medication reconciliation. The Institute for Healthcare Improvement recommends the nurse perform medication reconciliation when a client is transferred and The Joint Commission requires medication reconciliation when a client is admitted and when a client is discharged. 11.A A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take? A. Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form. Rationale: The nurse should attempt to get the client to sign the AMA form because this measure can help to defend the facility if a lawsuit ensues; however, the nurse should not tell the client she will not be permitted to leave the facility because this action could lead to charges of false imprisonment. B. Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit. Rationale: This action by the nurse is uncaring and the client could perceive it as a threat. C. Explain the risk the client faces if she leaves the facility. Rationale: The expected reference range for INR while a client is taking warfarin is 2 to 3.The nurse has an obligation to explain to the client that her INR is very high and she is at risk for bleeding. D. Ask the security department to guard the room to the client’s door. Rationale: This action could lead to charges of false imprisonment. 12.A A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? A. Delivering meal trays to clients in their rooms Rationale: Delivering meal trays is an appropriate task to delegate to a volunteer. B. Assisting a client who has difficulty seeing the foods on the tray while eating Rationale: Assisting a client who has a vision deficiency to eat is an appropriate task to delegate to a volunteer. C. Delivering a routine urine specimen to the laboratory Rationale: Delivering a routine urine specimen is an appropriate task for a volunteer. D. Observing a postoperative client who is confused Rationale: A nurse who uses delegation is responsible for delegating tasks to the right person. A volunteer does not have the training to intervene if this client tries to get out of bed or starts pulling at tubes. The observation of this client should be assigned to a member of the nursing staff. 13. An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first? A. Gather data about the nurse’s work performance and attendance history. Rationale: The first action the nurse should take is to conduct an investigation and determine if the allegations are true. B. Approach the involved nurse to discuss the behavior. Rationale: The nurse should approach the involved nurse to discuss the behavior; however, there is another action the nurse should take first. C. Notify the risk manager. Rationale: The nurse should notify the risk manager; however, there is another action the nurse should take first. D. Refer the nurse to the board of nursing diversion program. Rationale: The nurse should report the incident to the board of nursing if the suspicion of drug diversion is founded; however, there is another action the nurse should take first. 14.A A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client’s family about organ donation. The client’s spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? A. "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse’s organs." Rationale: The nurse should avoid giving her personal opinion. B. "What do you think your spouse would have wanted?" Rationale: Federal law requires facilities to have policies and procedures in place about making a request for organ and tissue donation at the time of death. The request is made by an employee, often a social worker, who has advanced training and can request the donations in a caring, sensitive manner. The role of the nurse is to provide emotional support to the family. Family members should consider the deceased person’s wishes when making their decision. C. "Most religions support organ donation, so don’t let that stand in the way." Rationale: While it is true that most religions support organ donation, there is no indication that this is a concern felt by the client’s spouse. D. "Don’t you think you will feel a little better about the situation if you donate your spouse’s organs?" Rationale: The nurse should not provide the client’s spouse with false reassurance. 15. A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate? A. "If you render aid in an accident, do not leave the scene until another competent person can take over." Rationale: Once the nurse renders aid, she has entered a nurse-client relationship and must continue to provide care until competent help arrives. B. "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse." Rationale: Good Samaritan laws require the nurse to render the level of care expected by a competent, prudent nurse in a similar situation. To win a malpractice suit against the nurse, the victim must prove the nurse was grossly negligent or careless. C. "Federal laws require a licensed nurse to render aid in an emergency." Rationale: Good Samaritan laws are state laws. Only a few states have duty to rescue laws, for example: Vermont, Minnesota, and Wisconsin. The nurse should know the laws of the state. D. "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws." Rationale: Good Samaritan laws protect the nurse in an emergency. Even in volunteer situations, Good Samaritan laws do not provide protection because in most cases an emergency does not exist. 16.A A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? A. The nurse identifies a broken piece of equipment. Rationale: This issue should be resolved by removing the equipment from the client care area and placing a work order for its repair. B. A staff member does not show up to work her assigned shift. Rationale: This is a staff problem that should be resolved between the staff member and the nurse manager. C. A client discovers that his dentures are missing. Rationale: This situation represents a variation from the normal standard of care. A change in the client's plan of care may be necessary if the client has difficulty eating or speaking without the dentures. In addition, the facility may be liable for replacing the missing dentures. D. The nurse has a disagreement with the nursing supervisor about inadequate staffing. Rationale: An incident report is not necessary for this situation. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 123.A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? A. The nurse separates the client's labia with her dominant hand. Rationale: The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon. If the nurse separated the labia with her dominant hand, it would be more difficult to insert the catheter in a sterile environment and could result in introduction of bacteria into the urinary tract. B. The nurse coats the indwelling urinary catheter with lubricant. Rationale: The nurse should coat the catheter tip with a water-soluble lubricant to reduce the risk for tissue trauma and discomfort. C. The nurse provides perineal care prior to inserting the urinary catheter. Rationale: The nurse should provide perineal care prior to inserting the urinary catheter. Providing perineal care to the client prior to insertion of the urinary catheter allows the nurse time to visualize the meatus and to reduce the risk of introducing bacteria into the urinary tract. D. The nurse applies the sterile drape prior to inserting the urinary catheter. Rationale: The nurse should apply a sterile drape and should don sterile gloves prior to inserting the urinary catheter to reduce the risk of introducing bacteria into the urinary tract. 124.A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict? A. Implement a resolution. Rationale: The nurse should implement a solution to resolve the conflict. However, there is another action the nurse should take first. B. Brainstorm solutions. Rationale: The nurse should brainstorm solutions to resolve the conflict. However, there is another action the nurse should take first. C. Identify the problem. Rationale: The first action the nurse should take using the nursing process is to assess the situation and identify the problem so that a solution is found. D. Evaluate the results. Rationale: The nurse should evaluate the solution to determine if the problem has been resolved. However, there is another action the nurse should take first. 125.A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Perform wound irrigation for a client. Rationale: The AP can change simple dressings, but the nurse should perform wound irrigation because it requires sterile technique and assessment skills. B. Evaluate pain relief for a client following the administration of a pain medication. Rationale: The RN should assess and interpret data and evaluate a client following the implementation of care. C. Measure and record intake and output for a client. Rationale: The AP can measure and record intake and output (I&O) for a client. It is the nurse's responsibility to review the recorded results and respond as necessary. D. Teach a client about low-sodium foods. Rationale: Food selections require teaching, assessment, and evaluation. A nurse should teach the client about making selections for a prescribed diet. 126.A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make? A. "It is time to sign the consent so your treatment can begin." Rationale: The nurse should verify the client has received enough information about the procedure before witnessing informed consent. Clients have the right to refuse to sign a consent form and should not be told that they must or should sign a consent form. B. "I would not have this type of surgery if I were you." Rationale: The nurse should not share personal opinions about treatment options. The role of the nurse is to advocate for the client and provide education. C. "Have you discussed other treatments with your provider?" Rationale: The nurse should seek clarification to determine what the client may or may not know about alternatives to the surgical procedure. The nurse should notify the provider about the need to discuss alternatives to surgery if necessary. Informed consent requires that the client is aware of the limitations and alternatives to the procedure. D. "I can inform the surgeon you do not want the surgery." Rationale: Although the client has the right to refuse any type of treatment, he has not stated he does not want the surgery. The client has indicated he is unclear about treatment options and requires further information before informed consent is obtained. 127.A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take? A. Counsel the provider to determine the cause of the substance abuse. Rationale: The responsibility of the nurse is to protect clients from injury. It is not the responsibility of the nurse to counsel the provider. B. Encourage clients to change to a different provider. Rationale: Encouraging clients to change services based on assumptions is defamation and could result injury to the reputation of the provider. The nurse could be sued for this action. C. Inform the state medical board for an immediate investigation. Rationale: It is the responsibility of hospital management and administration to follow up with any state licensure boards in cases of impairment or client negligence or harm. D. Notify the nursing supervisor of the concerns. Rationale: The nurse should notify hospital or nursing management of the concerns, and then ensure client safety. It is the responsibility of management to conduct an investigation. Client safety is the responsibility of the nurse. 128.A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make? A. Hospice care Rationale: Hospice care focuses on palliative care and not curative care. The purpose is to provide support to the client in the final phase of an illness with a focus on comfort measures to reduce pain and suffering in the home or in a hospice center. B. Restorative care Rationale: Restorative care assists the client in achieving and maintaining the highest possible level of function. This plan of care helps the client to achieve health goals and prevent deterioration by promoting independence and mobility. The systematic approach includes services such as physical therapy, occupational therapy, speech therapy, and cardiac rehabilitation. C. Mental health care Rationale: Mental health care is provided by psychiatrists, psychologists, counselors, or social workers to evaluate mental health as well as to teach adaptive coping strategies and communication skills to manage mental health disorders. D. Respite care Rationale: Respite care provides temporary relief for caregivers who care for disabled or chronically ill clients. The respite allows the caregiver an opportunity to complete errands and personal business, as well as time to recover both emotionally and physically. 129.A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy? A. Encourage the client to verbalize questions. Rationale: The nurse acts as a client advocate by providing the client with information needed to make informed decisions regarding care. B. Insist the client take prescribed medications. Rationale: Forcing or insisting that the client take the medication does not respect the client's right to an informed decision. The client has a right to information regarding their treatment and management of care. C. Inform the client that the medication is the same as taken at home. Rationale: In this response, the nurse does not encourage the client to ask questions regarding the medications prescribed. The nurse, as a client advocate, should teach the client about each medication, including its expected effects and adverse effects. D. Tell the client that refusal of the medication is considered noncompliance. Rationale: In this response, the nurse does not support the client or demonstrate client advocacy. The client has a right to refuse care and treatment after receiving full disclosure of information regarding prescribed medication, such as its action, expected effects, and adverse effects. 130.A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first? A. A client who was administered adalimumab for Crohn’s disease, has a serum calcium level of 10 mg/dL, and reports a headache Rationale: Crohn’s disease is a chronic disorder and a serum calcium level of 10 mg/dL is within the expected reference range. Although the nurse should address the needs of this client, there is another client the nurse should assess first. B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL Rationale: When using the acute vs. chronic approach to client care, the nurse should first assess the client who has diabetes and takes glipizide. An adverse effect of glipizide is hypoglycemia and a blood glucose level of 68 mg/dL is below the expected reference range; therefore, this is the client the nurse should assess first. C. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output Rationale: Expected findings for a client who has acute glomerulonephritis include hematuria, decreased urine output, and proteinuria. Although the nurse should address the needs of this client, there is another client the nurse should assess first. D. A client who was administered acyclovir for cellulitis reports pain in the affected leg Rationale: Expected findings for a client who has cellulitis include pain, erythema, and warmth in the affected area. Although the nurse should address the needs of this client, there is another client the nurse should assess first. 131.A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.) A. Raise all side rails on the client's bed. B. Obtain a prescription to restrain the client PRN. C. Check on the client hourly. D. Instruct the client in the use of the call light. E. Apply an ambulation alarm to the client's leg. Rationale: Raise all side rails on the client's bed is incorrect. Raising all side rails is considered a restraint. For a client who is disoriented, the risk for injury is greater with all side rails of the bed raised. If the client attempts to get out of bed, she may try to climb over the side rail or climb out at the foot of the bed. The nurse should place the bed in the lowest position. Obtain a prescription to restrain the client PRN is incorrect. Restraints are not prescribed PRN. Written restraint prescriptions are for a specific event and must have start and end times. Temporary restraints might be needed for clients who are confused, disoriented, repeatedly fall, or try to remove medical devices. Check on the client hourly is correct. Implementation of hourly rounds facilitates safety by reducing client falls. Hourly nursing actions should include toileting, turning, and ensuring that possessions and call lights are within reach. Instruct the client about the use of the call light is correct. Call lights are used for communication with nursing staff. When clients call for and wait for assistance before getting out of bed, the occurrence of accidents and falls is minimized. Nursing staff should make sure the call light is within the client's reach and should instruct the client frequently about its use. Apply an ambulation alarm to the client's leg is correct. The ambulation alarm signals when the client's leg is in a dependent position, such as over the side rail or on the floor. The signal alerts the staff to check on the client immediately. 132.A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse’s priority? A. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL Rationale: Both blood glucose levels are within the expected reference range. This client is stable; therefore, he is not the nurse’s priority. B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous Rationale: A change in the color of wound drainage from sanguineous to serosanguineous is an expected finding for a client who is 24 hr postoperative from surgery. Therefore, this client is not the nurse’s priority. C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 Rationale: The nurse should ask the client to rate his pain on a scale of 0 to 10 and provide care to manage the client’s pain. However, this client is not the nurse’s priority. D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg Rationale: A client who is postoperative is at risk for hemorrhage. A blood pressure decrease of 15 to 20 points is significant. This client is unstable; therefore, this client is the nurse’s priority. 133.A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene? A. The nurse uses clean gloves when discontinuing a client’s intravenous infusion. Rationale: The nurse should wear clean gloves when performing the procedure because they reduce the risk of transferring microorganisms from the client. B. The nurse empties a client’s drainable colostomy pouch when it is one-third full. Rationale: The nurse should empty the client’s colostomy pouch when it is one-third to one-half full. If the pouch becomes too heavy, it can cause the seal on the pouch to break the skin and subsequently expose the area around the ostomy to stool. C. The nurse uses the client’s telephone number as one form of identification when administering medications to a client. Rationale: The nurse should use two forms of identification prior to administering medications to a client. Acceptable forms of identification include telephone number, as well as the client’s name and birthdate. D. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis. Rationale: The nurse should avoid reaching across a sterile field; therefore, the nurse should place the sterile tray on the work surface so the top flap opens away from the body. 134.A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent? A. The client's partner Rationale: Legal decisions regarding health care must be made by a competent person or the person holding the durable power of attorney. B. The client Rationale: If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent. C. The client's daughter, who is the primary caregiver Rationale: Although the primary caregiver cares for the client, legal decisions regarding health care must be made by a competent person or the person holding the durable power of attorney. Caring for a client does not give the client's daughter legal authority regarding health care decisions. D. The client's son, who has a durable power of attorney Rationale: A durable power of attorney for health care is a legal document that designates an individual authorized to make health care decisions for a client who is unable. The client's son should be familiar with the client's wishes. 135.A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.) A. The date of the incident B. The name of the provider who prescribed the medication C. The potential adverse effects of the medication D. The time the client was to receive the medication E. The client's vital signs Rationale: The date of the incident is correct. When a nurse discovers a medication error, it is her legal responsibility to complete an incident report. A health care agency can use incident reports to monitor incidents and accidents in order to prevent future occurrences. The report should only include factual information about the incident such as the date. The name of the provider who prescribed the medication is incorrect. The nurse does not need to include the name of the provider who prescribed the medication as this information is part of the client's medical record. The potential adverse effects of the medication is incorrect. The nurse should only include factual information about the incident and not potential effects. The time the client was to receive the medication is correct. The nurse should include the time the client was to receive the medication because this pertains directly to the incident of the omitted medication. The client's vital signs is correct. The nurse should assess the client as soon as she discovers the error and should include the assessment data in the report. 136.A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which of the following is the appropriate action by the nurse manager? A. Ask other staff nurses about the level of care the specific staff nurse provides. Rationale: This action is inappropriate because it does not directly address the issue and does not show respect for the specific staff nurse. B. Address the concern with the specific staff nurse. Rationale: The nurse manager should use the conflict management skill collaborating to resolve the conflict. The nurse manager should be assertive and ask the specific staff nurse about the problem. C. Recommend the specific staff nurse be transferred to another unit. Rationale: This action is inappropriate because it does not directly address the issue and does not show respect for the specific nurse. D. Notify the human resources department about the request. Rationale: This action is inappropriate because it does not directly address the issue and does not show respect for the specific nurse. 137.A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent? A. A client who has a punctured femoral artery Rationale: A client who has a punctured femoral artery requires immediate attention because it is life-threatening; therefore, the nurse should identify this client as emergent or red-tagged. B. A client who has multiple fractures Rationale: A client who has multiple fractures requires treatment within 2 hr. The nurse should identify this client as urgent or yellow-tagged. C. A client who has a red rash over his abdomen Rationale: A client who has a red rash over his abdomen can wait 2 hr or more to receive treatment. The nurse should identify this client as nonurgent or green-tagged. D. A client who reports severe flank pain radiating to the groin Rationale: A client who reports severe flank pain radiating to the groin requires treatment within 2 hr. the nurse should identify this client as urgent or yellow-tagged. 138.A nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take? A. Vigorously rub the skin following a decontamination shower. Rationale: Sarin gas is a nerve agent that is spread through the air and can be inhaled or absorbed through the skin. Following decontamination with soap and water or bleach, the nurse should pat the skin dry to avoid rubbing more of the agent into the skin. B. Initiate seizure precautions. Rationale: Symptoms of sarin gas exposure include neurologic responses including insomnia, impaired judgment, a loss of consciousness, and seizures. The nurse should anticipate the need for seizure precautions and should prepare the room with padding, suction equipment, and oxygen. C. Provide respiratory support with a plastic oral airway. Rationale: Symptoms of sarin gas exposure includes bronchoconstriction and laryngeal spasms requiring support of the airway. The nurse should avoid using plastic artificial airways because they can absorb the sarin gas resulting in continued exposure of the client to the agent. D. Prepare to administer amyl nitrate. Rationale: Symptoms of nerve gas exposure mimic those of a cholinergic crisis. Medications used in treatment include atropine, pralidoxime, and diazepam. Amyl nitrate is used in the treatment of blood agent exposure, such as cyanide.