ATI NU2508 Leadership Final Exam

ATI NU2508 Leadership Final Exam Related

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A nurse is caring for a client who is postoperative following a hip replacement. The client's surgical drain has minimal output. Which of the following actions should the nurse take first?

  • A. Notify the provider of the minimal drain output.
  • B. Flush the drain with sterile saline.
  • C. Document the drain output in the medical record.
  • D. Check the drain for kinks or obstructions.
Correct Answer: D

Rationale: Checking the drain for kinks or obstructions is the first step to determine if the minimal output is due to a mechanical issue, which can often be resolved without further intervention.

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A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions?

  • A. Withholding a dose of narcotic pain medication when the client has respiratory depression
  • B. Discussing advance directives with the client and the client's family
  • C. Providing comfort care measures to the client
  • D. Allowing the client's family unlimited visitation at the time of death
Correct Answer: A

Rationale: Correct Answer: A

Rationale: Nonmaleficence is the ethical principle of doing no harm. In this scenario, withholding a dose of narcotic pain medication when the client has respiratory depression aligns with this principle as administering the medication could further compromise the client's respiratory status and potentially harm them. By withholding the medication, the nurse is prioritizing the client's safety and well-being.

Summary of Incorrect Choices:
B: Discussing advance directives is important but does not directly relate to nonmaleficence in this context.
C: Providing comfort care measures is essential but does not specifically demonstrate the principle of nonmaleficence.
D: Allowing unlimited visitation may support emotional well-being but does not directly address the principle of nonmaleficence.

A nurse is conducting a performance evaluation for an assistive personnel (AP). Which of the following actions by the AP should the nurse identify as requiring further training?

  • A. The AP checks a client's identification band before providing a meal tray.
  • B. The AP reports a client's complaint of pain to the nurse immediately.
  • C. The AP uses an alcohol-based hand rub after assisting a client with ambulation.
  • D. The AP leaves a client's bed in the lowest position without raising side rails for a client at risk for falls.
Correct Answer: D

Rationale: The correct answer is D. Leaving a client's bed in the lowest position without raising side rails for a client at risk for falls is a safety violation. The nurse should identify this action for further training because it puts the client at risk of injury. Lowering the bed and raising side rails are essential fall prevention measures. Checking the client's identification band (A) ensures correct client identification. Reporting client complaints of pain (B) promptly is important for timely intervention. Using hand rub after assisting a client (C) promotes infection control. Options E, F, and G are not provided in the question. In summary, choice D is correct as it pertains to client safety, while the other options demonstrate appropriate nursing actions.

A nurse is caring for a client who is postoperative and reports a pain level of 8 on a scale of 0 to 10. Which of the following actions should the nurse take first?

  • A. Administer the prescribed analgesic.
  • B. Notify the provider of the pain level.
  • C. Reposition the client for comfort.
  • D. Document the pain level in the medical record.
Correct Answer: A

Rationale: The correct answer is A: Administer the prescribed analgesic first. Managing pain is a priority to ensure the client's comfort and prevent complications. Administering the analgesic promptly is essential to relieve the client's pain and improve their overall well-being. Notifying the provider (B) can be done after addressing the immediate need for pain relief. Repositioning the client (C) may provide some comfort but should come after administering pain medication. Documenting the pain level (D) is important, but addressing the pain itself takes precedence.

A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate?

  • A. I am sure these feelings will pass once you go home.
  • B. Tell me what you understand about your illness.
  • C. Tell me why you feel hopeless.
  • D. If I were you, I would ask for a referral to hospice care.
Correct Answer: B

Rationale: The correct answer is B: "Tell me what you understand about your illness." This response shows active listening and encourages the client to express their thoughts and feelings, fostering trust and understanding. It allows the nurse to assess the client's knowledge and perception, helping tailor support accordingly. Choice A dismisses the client's feelings, lacking empathy. Choice C may come off as confrontational, potentially shutting down communication. Choice D imposes the nurse's opinion on the client. Choices E, F, and G are not applicable. In summary, choice B promotes therapeutic communication and client-centered care, while the other choices may hinder the nurse-client relationship.

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 opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
  • B. The nurse uses clean gloves when discontinuing a client's intravenous infusion.
  • C. The nurse uses the client's telephone number as one form of identification when administering medications to a client.
  • D. The nurse empties a client's drainable colostomy pouch when it is one-third full.
Correct Answer: C

Rationale: The correct answer is C. Using a client's telephone number as identification is a violation of privacy and confidentiality. It is not a secure or reliable form of identification and could lead to errors in medication administration. The other choices do not indicate immediate intervention is needed. A: Opening the top flap of a sterile tray is incorrect but may not cause immediate harm. B: Using clean gloves for discontinuing an IV infusion is incorrect, but can be corrected easily. D: Emptying a colostomy pouch when it is one-third full is appropriate to prevent skin irritation and leakage.