Extract:

Question 1 of 5

A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?

A. Two staff members have called to say they will be absent.B. Transport assistance is unavailable to take a client to occupational therapy.C. The emergency department nurse is waiting to give report on a new admissionD. A nurse on the previous shift wrote an incident report about a medication error.

Correct Answer: C

Rationale: The ED report on a new admission is urgent for care continuity. Staffing issues (
A), transport (
B), and incident reports (
D) are less immediate.

Question 2 of 5

A nurse is caring for a client who is experiencing cardiac arrest and has a do-not-resuscitate (DNR) prescription. The client's partner requests medical intervention. Which of the following actions should the nurse take?

A. Have the client's partner sign a consent form to reverse the DNR prescription.B. Begin chest compressions on the client.C. Contact social services to confer with the client's partner.D. Adhere to the client's treatment decision.

Correct Answer: D

Rationale: Adhering to the DNR respects the client’s wishes. Reversing the DNR (
A) or starting compressions (
B) violates the order, and social services (
C) is not immediate.

Question 3 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: Identifying the medication name and dosage (
C) and including the time of the error (E) are essential for a thorough incident report, aiding investigation and corrective actions. Placing the report in the medical record (
A) compromises objectivity, no provider order is needed (
B), and personal copies (
D) violate confidentiality.

Question 4 of 5

A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?

A. A client who has bipolar disorder and is exhibiting signs of hallucinationB. A client who has two open chest wounds with a left tracheal deviationC. A client who has a neck injury and is unable to breathe spontaneouslyD. A client who has major burns over 75% of her body surface area

Correct Answer: C

Rationale: A neck injury with inability to breathe spontaneously is the most critical, requiring immediate airway intervention. Chest wounds (
B), burns (
D), and hallucinations (
A) are less urgent.

Question 5 of 5

A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?

A. Unilateral ptosisB. Altered level of consciousnessC. Diminished hand-to-mouth coordinationD. Impaired voluntary cough

Correct Answer: D

Rationale: Impaired voluntary cough indicates swallowing difficulties, warranting speech-language pathology referral. Ptosis (
A) is neuromuscular, altered consciousness (
B) needs broader evaluation, and coordination (
C) is for occupational therapy.

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ATI RN Leadership 2023 I Questions

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