ATI RN Leadership Protocol

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Sample questions from ATI RN Leadership Protocol

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift, the charge nurse receives report on four clients. Which client should the nurse assess first?

   • A.A client 68 years of age who is awaiting discharge instructions after an uncomplicated laparoscopic procedure
   • B.A client 31 years of age with a healed forearm fracture who reports pain of 4 on a 0-to-10 scale
   • C.A client 42 years of age with pneumonia whose oxygen saturation decreased from 95% to 89% on 2 L/min by nasal cannula
   • D.A client 55 years of age who requests assistance to the bathroom after receiving a scheduled antihypertensive

   Rationale: The client with pneumonia and a falling oxygen saturation has a potential airway and breathing problem that requires prompt assessment. Discharge instructions, toileting assistance, and moderate pain are important but are less urgent than worsening oxygenation. Prioritize using airway, breathing, and circulation before routine needs.

2. 2.A charge nurse is assigning care on a medical-surgical unit. Which tasks are appropriate to delegate to an experienced unlicensed assistive personnel (UAP) for a stable client 74 years of age? Select all that apply.

   • A.Obtain and record routine vital signs
   • B.Assist the client with bathing and dressing
   • C.Teach the client how to use a walker safely
   • D.Measure and document the client's oral intake and urine output
   • E.Evaluate whether a newly administered analgesic relieved the client's pain

   Rationale: Obtaining routine vital signs, assisting with bathing and dressing, and measuring and recording intake and output are predictable tasks that may be delegated to a trained UAP for a stable client. Evaluating pain relief requires nursing assessment and cannot be delegated. Teaching walker use requires the nurse's judgment and evaluation of learning, so it is not an appropriate UAP assignment.

3. 3.In the emergency department, a client 76 years of age is being treated for a urinary infection. Refer to the client's chart. Which action should the nurse take first?

   • A.Notify the provider of the client's acute change in mental status and falling blood pressure
   • B.Document the client's confusion as an expected finding in an older adult
   • C.Ask the UAP to obtain another set of vital signs in 2 hours
   • D.Provide written information about preventing future urinary infections

   Rationale: The client has new confusion, tachycardia, and a blood pressure decrease from 118/72 to 88/54 mm Hg, findings concerning for clinical deterioration and possible sepsis. The nurse should promptly communicate the change and initiate the facility's escalation process rather than wait 2 hours. Confusion is not an expected consequence of aging, and infection-prevention teaching is not the immediate priority.

4. 4.A provider prescribes a medication dose that is markedly higher than the usual safe range. The nurse has not yet administered the medication. Which action should the nurse take?

   • A.Ask another nurse to administer the medication instead
   • B.Hold the medication and clarify the prescription with the provider
   • C.Document the concern and administer the dose at the next scheduled time
   • D.Administer the dose because the provider is responsible for the prescription

   Answer and rationale are in the full material.

5. 5.During a home visit, a client 63 years of age tells the nurse, "I have been taking twice the prescribed dose of my blood pressure medicine because my readings were high." Which response is the nurse's priority?

   • A."Stop taking the medication until your next clinic appointment."
   • B."You should restart the prescribed dose and avoid checking your blood pressure."
   • C."I will document your decision, but medication changes are your responsibility."
   • D."Tell me what dose you took and when you last took it."

   Answer and rationale are in the full material.