ATI RN Leadership 2023 I

Question 1 of 5

A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?

A. Close the fire doors and the doors to the clients' rooms.B. Extinguish the fire.C. Activate the fire alarmD. Remove all clients from the unit.

Correct Answer: C

Rationale: The correct answer is C: Activate the fire alarm. This is the most important immediate action to ensure the safety of all individuals in the facility. Activating the fire alarm will alert everyone in the building to evacuate and summon the fire department. Closing fire doors (
A) and removing all clients from the unit (
D) are important steps, but activating the fire alarm takes precedence as it initiates the emergency response process. Extinguishing the fire (
B) can be dangerous if not trained properly and can waste precious time. It is essential to prioritize the safety of all individuals by activating the fire alarm first.

Question 2 of 5

A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? (Select all that apply.)

A. Place a copy of the completed report in the client's medical record.B. Obtain an order from the client's provider to complete the report.C. Identify the medication name and dosage administered to the client in the report.D. Make a copy of the incident report for personal record keeping.E. Include the time the medication error occurred in the report.

Correct Answer: C,E

Rationale: The correct answers are C and E. In an incident report regarding a medication error, the nurse should identify the medication name and dosage administered to the client (choice
C) to provide crucial information for analysis and prevention of future errors. Including the time the medication error occurred (choice E) is essential for understanding the context and timeline of the event. These details help in investigating the error, determining root causes, and implementing corrective actions. Placing a copy of the report in the client's medical record (choice
A) is not recommended as incident reports are typically kept separate for confidentiality and quality improvement purposes. Obtaining an order from the client's provider to complete the report (choice
B) is unnecessary and delays reporting. Making a copy of the incident report for personal record keeping (choice
D) is not standard practice and may compromise the confidentiality of the information.

Question 3 of 5

A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?

A. Reorienting the client several times throughout the dayB. Performing an updated cognitive assessment on the clientC. Requesting a referral for the client to attend reminiscent therapy sessionsD. Providing assistance for the client when ambulating down the hall

Correct Answer: C

Rationale: The correct answer is C because requesting a referral for the client to attend reminiscent therapy sessions is an action that aligns with advocating for the client's best interest. Reminiscent therapy can help individuals with Alzheimer's by stimulating memory and improving their quality of life. Reorienting the client (choice
A) is important but not necessarily advocating. Performing an updated cognitive assessment (choice
B) is part of the nurse's responsibilities but not specifically advocating. Providing assistance with ambulation (choice
D) is basic care and not directly related to advocacy.

Question 4 of 5

A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?

A. A nurse explains to a client's family that a DNR order includes withholding comfort measures.B. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.C. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min.D. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better.

Correct Answer: A

Rationale: The correct answer is A because explaining to a client's family that a DNR order includes withholding comfort measures is incorrect and unethical. A DNR order only pertains to resuscitative measures.

Choices B, C, and D all demonstrate ethical behavior. B respects the nurse's right to conscientious objection, C provides appropriate pain management, and D maintains safety for a confused client.

Question 5 of 5

A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?

A. Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.B. Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago.C. Administer a bronchodilator two times a day for child who has cystic fibrosis.D. Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet.

Correct Answer: D

Rationale: The correct answer is D because a high-protein, low-fiber diet is not recommended for someone with ulcerative colitis during an exacerbation. A high-protein diet can be hard to digest and may worsen symptoms. Instead, a low-residue diet is typically recommended, which is low in fiber to reduce bowel movements and irritation.
Therefore, the care plan needs to be revised to align with the appropriate dietary recommendations for ulcerative colitis.

Choices A, B, and C are not correct because maintaining eye shields for phototherapy, checking neurovascular status after a hip spica cast placement, and administering a bronchodilator for cystic fibrosis are appropriate and necessary interventions in these scenarios.

ATI RN Leadership 2023 I | Nurselytic

Nurselytic

ATI RN

ATI RN