ATI LEADERSHIP PROCTORED EXAM TEST BANK WITH RATIONALES (NGN)

31.A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client’s provider, and completes an incident report, which of the following actions should the nurse take? A. Make a copy of the incident report for the provider. Incidence reports are confidential tools used by the facility to improve client care. They are never copied. B. Submit the incident report to the risk manager. Rationale:The purpose of an incident report is to provide information to the risk manager who will investigate the incident and work with other members of the health care team to control risks of client injury. C. Place the incident report in the client's chart. Rationale:Incident reports are confidential tools used by the facility to improve client care. They are never placed in the client's chart. If there is a lawsuit and the incident report is in the client’s chart, the attorney can subpoena the document and use its contents as evidence. D. Document in the chart that an incidence report has been filed. Rationale:Incident reports are confidential tools used by the facility to improve client care. They are never referred to in a client's chart. If there is a lawsuit and the incident report is referenced in the client’s chart, the attorney can subpoena the document and use its contents as evidence. 32.A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer? A. Transporting a school-age client who is in traction to another department Rationale:To ensure client safety, the nurse is responsible for delegating tasks to the right people. The nurse should avoid assigning this task to the volunteer because the individual who performs this task must understand the principles of traction. A volunteer does not have the requisite skill to perform this task. B. Playing a computer video game with an adolescent who has sickle cell disease Rationale:This is an appropriate and safe assignment for the volunteer. It provides both socialization and diversional activity to the client in traction. C. Reading a book to a preschool client who has AIDS Rationale:This is an appropriate and safe assignment for the volunteer. It provides a diversional activity for the client. D. Rocking an infant who was admitted for croupRationale: This is an appropriate and safe assignment for the volunteer. It provides comfort for the client. 33.A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse? A. "Let's talk about something else." Rationale:While this appears to be a response meant to change the subject, this response does not make it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse. B. "Whether or not I am a good lover is irrelevant." Rationale:While this appears to be a response meant to change the subject, this response does not make it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse. C. "Speaking to me like that makes me uncomfortable." Rationale:This assertive response makes it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse. D. "You need to lower your voice. Others can hear you." Rationale:This response does not make it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse. In fact, it could be considered by the harasser as encouragement. 34.A nurse in a provider’s office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse? A. BUN 15 mg/dL Rationale:This BUN level is within the expected reference range. It does not require follow up by the nurse. B. Platelet count 60,000/mm3 Rationale:This platelet count is below the expected reference range. A low platelet count places the client at risk for bleeding; therefore, the nurse should follow up on this finding. C. WBC 6,000/mm3 Rationale:This WBC is within the expected reference range and does not require follow up by the nurse. D. Hemoglobin 14 g/dL Rationale:This hemoglobin level is within the expected reference range and does not require follow up by the nurse. 35.A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first? A. Collect a stool sample for ova and parasites from a school-age child Rationale:Although the AP should collect a stool sample for ova and parasites, there is another task the AP should perform first. B. Engage a toddler in play. Engaging a toddler in play is important because it provides diversion and promotes the toddler’s sense of security, but there is another task that the AP should perform first. C. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma. Rationale:Although the AP should provide personal hygiene measures for the adolescent, including washing the client’s hair, there is another task the AP should perform first. D. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate. Rationale:The infant who is postoperative from a surgical correction of a cleft palate is at risk for damage to the suture line and an elbow immobilizer decreases the risk of this complication; therefore, this is the task the AP should perform first. 36.A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following? A. Keeping an appointment with a client Rationale:Fidelity is the duty to keep one's promises or word. Keeping an appointment the nurse has made with the client is an example of fidelity