Detailed Answer Key Leadership Practice ATI
Created on:03/25/2019 Page1
1.A nurse is transcribing a client’s medication prescriptions and is having difficulty reading a written prescriptionbythe provider. Which of the following nursing actions should the nurse take?
A.Clarify the prescription with the client’s family.
Rationale:The nurse should not clarify the medication prescription with the client’s family, because thisaction
could be a breach of confidentiality.
B.Interpret the prescription based on the client’s health history.
Rationale:The nurse should not interpret the medication prescription based on the client’s health history, because incorrect information may result.
C.Ask the pharmacist for clarification of the prescription.
Rationale:The nurse should not ask the pharmacist for clarification of the prescription, because incorrect information may result.
D.Contact the provider to clarify the prescription.
Rationale:The nurse should contact the provider for clarification of the prescription to confirm the correct interpretation of the prescription.
2.A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success ofthechanges?
A.Establish a benchmark to identify a standard of performance.
Rationale:A benchmark measures the practices of an organization against a best–performing organization in order to develop improvement of performance. It is used as a tool to determine the desired standard of performance.
B.Compare the number of medication errors before and after the action was implemented.
Rationale:Preimplementation and postimplementation statistics for medication errors will provide information to determine the success of the actions.
C.Provide the staff with a questionnaire to quantify staff satisfaction with the changes.
Rationale:A questionnaire that determines staff satisfaction can provide a means of communication regarding the new practice, but it does not measure the success of the new measures.
D.Conduct a study about the time and money costs of implementing the change.
Rationale:A study about the time and money costs of the effort is useful for comparing the success
ofthechanges to the cost required to make them. However, this will not measure how
successfulthechanges were in reducing medication errors. 3.A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which ofthefollowing assignments is an example of overdelegation?
A.Assigning two assistive personnel (AP) to ambulate all clients
Rationale:Assigning two APs to ambulate 10 clients follows the rights of delegation and expectations of the APs. It is not an example of overdelegation.
B.Assigning a new graduate nurse to perform a wet-to-dry dressing change
Rationale:Assigning a new graduate nurse to perform a wet-to-dry dressing change follows the rights of delegation and expectations of the nurse. It is not an example of overdelegation.
C.Assigning the most efficient AP to perform glucometer monitoring for each client
Rationale:Asking the most efficient AP to perform glucometer testing based on her efficiency in performing this task is an example of overdelegation. This can result in the AP becoming overworked and tired, thus decreasing productivity.
D.Assigning the most competent RN to perform a central line dressing change
Rationale:Assigning the most competent RN to perform a central line dressing change follows the rights of delegation and expectations of the nurse. It is not an example of overdelegation.
4.A nurse on a medical unit is planning care for several clients. Which of the following clients should benefitmostfrom the nurse acting as an advocate?
A.A client who has previously undergone a procedure that is to be performed for a second time
Rationale:The nurse supports the client in this situation, but it is not an example of a client benefitting most from the nurse acting as an advocate.
B.A client who has been educated on treatment options and chooses alternative treatments
Rationale:The nurse supports the client in this situation, but it is not an example of a client benefitting most from the nurse acting as an advocate.
C.A client who makes an informed decision not to participate in chemotherapy treatment
Rationale:The nurse supports the client in this situation, but it is not an example of a client benefitting most from the nurse acting as an advocate.
D.An older adult client who has no family and is uncertain about moving to assisted living
Rationale:The nurse acts as an advocate by ensuring the client has correct information to make an appropriate decision in selecting needed services. This is an example of a client benefitting most from the nurse acting as an advocate.
5.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. Whichof 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.
6.A public health nurse is assessing an older adult client who lives with a family member. The nurse identifiesseveralbruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first?
A.Document the bruises in the client's chart.
Rationale:The nurse should document the bruises in the client’s chart after providing care to comply with legal guidelines; however, there is another action the nurse should take first.
B.Report the findings to a supervisor.
Rationale:The greatest risk to this client is further injury from continued abuse; therefore, the first action the nurse should take is to report the findings to a supervisor. Nurses are required to report suspected cases of child and older adult abuse.
C.Provide the client with a crisis hotline number.
Rationale:The nurse should provide the client and family with a crisis hotline number in case emergency help is needed; however, there is another action the nurse should take first.
D.Discuss respite care with the client’s family.
Rationale:The nurse should discuss respite care with the client’s family to prevent caregiver role strain; however, there is another action the nurse should take first.
7.A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following
Created on:03/25/2019 Page1
1.A nurse is transcribing a client’s medication prescriptions and is having difficulty reading a written prescriptionbythe provider. Which of the following nursing actions should the nurse take?
A.Clarify the prescription with the client’s family.
Rationale:The nurse should not clarify the medication prescription with the client’s family, because thisaction
could be a breach of confidentiality.
B.Interpret the prescription based on the client’s health history.
Rationale:The nurse should not interpret the medication prescription based on the client’s health history, because incorrect information may result.
C.Ask the pharmacist for clarification of the prescription.
Rationale:The nurse should not ask the pharmacist for clarification of the prescription, because incorrect information may result.
D.Contact the provider to clarify the prescription.
Rationale:The nurse should contact the provider for clarification of the prescription to confirm the correct interpretation of the prescription.
2.A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success ofthechanges?
A.Establish a benchmark to identify a standard of performance.
Rationale:A benchmark measures the practices of an organization against a best–performing organization in order to develop improvement of performance. It is used as a tool to determine the desired standard of performance.
B.Compare the number of medication errors before and after the action was implemented.
Rationale:Preimplementation and postimplementation statistics for medication errors will provide information to determine the success of the actions.
C.Provide the staff with a questionnaire to quantify staff satisfaction with the changes.
Rationale:A questionnaire that determines staff satisfaction can provide a means of communication regarding the new practice, but it does not measure the success of the new measures.
D.Conduct a study about the time and money costs of implementing the change.
Rationale:A study about the time and money costs of the effort is useful for comparing the success
ofthechanges to the cost required to make them. However, this will not measure how
successfulthechanges were in reducing medication errors. 3.A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which ofthefollowing assignments is an example of overdelegation?
A.Assigning two assistive personnel (AP) to ambulate all clients
Rationale:Assigning two APs to ambulate 10 clients follows the rights of delegation and expectations of the APs. It is not an example of overdelegation.
B.Assigning a new graduate nurse to perform a wet-to-dry dressing change
Rationale:Assigning a new graduate nurse to perform a wet-to-dry dressing change follows the rights of delegation and expectations of the nurse. It is not an example of overdelegation.
C.Assigning the most efficient AP to perform glucometer monitoring for each client
Rationale:Asking the most efficient AP to perform glucometer testing based on her efficiency in performing this task is an example of overdelegation. This can result in the AP becoming overworked and tired, thus decreasing productivity.
D.Assigning the most competent RN to perform a central line dressing change
Rationale:Assigning the most competent RN to perform a central line dressing change follows the rights of delegation and expectations of the nurse. It is not an example of overdelegation.
4.A nurse on a medical unit is planning care for several clients. Which of the following clients should benefitmostfrom the nurse acting as an advocate?
A.A client who has previously undergone a procedure that is to be performed for a second time
Rationale:The nurse supports the client in this situation, but it is not an example of a client benefitting most from the nurse acting as an advocate.
B.A client who has been educated on treatment options and chooses alternative treatments
Rationale:The nurse supports the client in this situation, but it is not an example of a client benefitting most from the nurse acting as an advocate.
C.A client who makes an informed decision not to participate in chemotherapy treatment
Rationale:The nurse supports the client in this situation, but it is not an example of a client benefitting most from the nurse acting as an advocate.
D.An older adult client who has no family and is uncertain about moving to assisted living
Rationale:The nurse acts as an advocate by ensuring the client has correct information to make an appropriate decision in selecting needed services. This is an example of a client benefitting most from the nurse acting as an advocate.
5.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. Whichof 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.
6.A public health nurse is assessing an older adult client who lives with a family member. The nurse identifiesseveralbruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first?
A.Document the bruises in the client's chart.
Rationale:The nurse should document the bruises in the client’s chart after providing care to comply with legal guidelines; however, there is another action the nurse should take first.
B.Report the findings to a supervisor.
Rationale:The greatest risk to this client is further injury from continued abuse; therefore, the first action the nurse should take is to report the findings to a supervisor. Nurses are required to report suspected cases of child and older adult abuse.
C.Provide the client with a crisis hotline number.
Rationale:The nurse should provide the client and family with a crisis hotline number in case emergency help is needed; however, there is another action the nurse should take first.
D.Discuss respite care with the client’s family.
Rationale:The nurse should discuss respite care with the client’s family to prevent caregiver role strain; however, there is another action the nurse should take first.
7.A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following
