ATI PN FUNDAMENTALS LATEST TEST BANK REAL EXAM 800+ QUESTIONS AND CORRECT ANSWERS WITH RATIONALES|PN FUNDAMENTALS ATI PROCTORED EXAM 2023|AGRADE 1. A 75 -year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk for Impaired Skin Integrity? Arrange the steps of the nursing process in the sequence in which they generally occur. 1. Assessment 2. Evaluation 3. Planning outcomes 4. Planning interventions 5. Diagnosis A) 5, 2, 1, 4, 3 B) 1, 2, 3, 4, 5 C) 1, 5, 3, 4, 2 D) 4, 1, 2, 5, 3 Answer: C Rationale: Logically, the steps are assessment, diagnosis, planning outcomes, planning interventions, and evaluation. Keep in mind that steps are not always performed in this order, depending on the patient's needs, and that steps overlap. 2. At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? A) Complete an occurrence report before leaving. B) Do nothing; the next nurse will document it was done. C) Write the note of the dressing change into an earlier note. D) Make a late entry as an addition to the narrative notes. Answer: D Rationale: If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record th e wound change as performed. 3. The charge nurse asks the nursing assistive personnel (NAP) to give a bed bath to a patient with end -stage chronic obstructive pulmonary disease. How should the NAP proceed? A) Bathe the patient's entire body using 8 to 10 washcloths. B) Assist the patient to a chair and provide bathing supplies. C) Saturate a towel and blanket in a plastic bag, and then bathe the patient. D) Assist the patient to the bathtub and provide a bath chair. Answer: A Rationale: A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water; warms in them in a microwave , and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient's body is bathed with a fresh cloth. A bag bath is not given in a chair or in the tub. 5. Which pain management task can the nurse safely delegate to nursing assistive personnel? A) Asking about pain during vital signs B) Evaluating the effectiveness of pain medication C) Developing a plan of care involving nonpharmacologic interventions D) Administering over-the-counter pain medications Answer: A Rationale: The nurse can delegate the task of asking about pain when nursing assistive personnel (NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Administering over -the-counter and prescription medications is the responsibility of the registered nurse or licensed practical nurse. 6. Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)? A) Hepatitis B B) Occasional alcohol use C) Allergy to aspirin D) Gastric irritation with bleeding Answer: A Rationale :Even in recommended doses, acetaminophen can cause severe hepatotoxicity in patients with liver disease, such as hepatitis B. Patients who consume alcohol regularly should also use acetaminophen cautiously. Those allergic to aspirin or other nonsteroidal anti - inflammatory drugs (NSAIDs) can use acetaminophen safely. Acetaminophen rarely causes gastrointestinal (GI) problems; therefore, it can be used for those with a history of gastric irritation and bleeding. 7. Which action should the nurse take before administeri ng morphine 4.0 mg intravenously to a patient complaining of incisional pain? A) Assess the patient's incision. B) Clarify the order with the prescriber. C)Assess the patient's respiratory status. D)Monitor the patient's heart rate. Answer: C Rationale : Before administering an opioid analgesic, such as morphine, the nurse should assess the patient's respiratory status because opioid analgesics can cause respiratory depression. It is not necessary to clarify the order with the physician because morphine 4 mg IV is an appropriate dose. It is not necessary to monitor the patient's heart rate. 8. Which action should the nurse take when preparing patient -controlled analgesia for a postoperative patient? A) Caution the patient to limit the number of times he presses the dosing button. B) Ask another nurse to double -check the setup before patient use. C) Instruct the patient to administer a dose only when experiencing pain. D) Provide clear, simple instructions for dosing if the patient is cognitively impaired. Answer: B Rationale: As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double -check the setup before patient use. The nurse should reassure the patient that the pump has a lockout feature that prevents him from overdosing even if he continues to push the dose administration button. The nurse should also instruct the patient to administer a dose before potentially painful activities, such as walking. Patient -controlled analgesia is contraindicated for those who are cognitively impaired. 9. The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? A) Immediately B) In 10 minutes C) In 15 minutes D) In 60 minutes Answer:D Rationale: Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the nurse should reassess the patient's pain 60 minutes after administration. The nurse should reassess pain after 10 minutes when administering codeine by the intramuscular or subcutaneous routes. Drugs administered by the intravenous (IV) route are effective almost immediately; however, codeine is not recommended for IV administration. 10. Which nonsteroidal anti-inflammat ory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis? A) Ibuprofen (Motrin) B) Celecoxib (Celebrex) C) Aspirin (Ecotrin) D) Indomethacin (Indocin) Answer: C Rationale : Aspirin is a unique NSAID that inhibits platelet aggregation. Low -dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation. 11. A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing? A) Infection at the catheter insertion site B) Side effect of the epidural analgesic C) Epidural catheter migration D) Spinal cord damage Answer: C Rationale: The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side effect associated with epidural analgesics. These are common signs of catheter migration, not spinal cord damage. 12. Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply): A) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing B) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening C)Heart rate was 76 before eating and is 60 after eating D)Respiratory rate was 14 when standing and is 22 after walking Answer: A,B Rationale: The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension. The change in heart rate is abnormal; heart rate usually increases slightly after eating rather than decreasing. The temperatures are within normal range for the rectal route, and temperature increases throughout the day. It is normal to have an increased respiratory rate after exercise. 13. The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has: A) Crackles B) Rhonchi C) Stridor D) Wheezes Answer: C Rationale : Stridor is a sign of respiratory distress, possibly airway obstruction. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illness and are potentially serious but do not necessarily indicate respiratory distress that requires immediate medical attention. 14. The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the: A) Pulse deficit B) Blood pressure C) Apical pulse D) Pulse pressure
