ATI PHARMACOLOGY PROCTORED EXAM
(Detail Solutions)
1. Which action should the nurse take first during the initial phase of
implementation?
a. Determine patient outcomes and goals.
b. Prioritize patient’s nursing diagnoses.
c. Evaluate interventions.
d. Reassess the patient.
ANS: D
Assessment is a continuous process that occurs each time the nurse interacts with
a patient. During the initial phase of implementation, reassess the patient.
Determining the patient’s goals and prioritizing diagnoses take place in the
planning phase before choosing interventions. Evaluation is the last step of the
nursing process.
2. Vital signs for a patient reveal a high blood pressure of 187/100. Orders
state to notify the health care provider for diastolic blood pressure greater than
90. What is the nurse’s first action?
a. Follow the clinical protocol for a stroke.
b. Review the most recent lab results for the
patient’s potassium level. Assess the patient
for other symptoms or problems, and then
notify the
c. health care provider.
Administer an antihypertensive medication from the stock supply, and
d. then notify the health care provider.
ANS: C
Communication to other health care professionals must be timely, accurate, and
relevant to a patient’s clinical situation. The best answer is to reassess the patient
for other symptoms or problems, and then notify the health care provider
according to the orders. Reviewing the potassium level does not address the
problem of high blood pressure. The nurse does not follow the protocol since the
order says to notify the health care provider. The orders read to notify the health
care provider, not administer medications.
1
,3. Which initial intervention is most appropriate for a patient who has a new onset
of chest pain?
a. Reassess the patient.
b. Notify the health care provider.
c. Administer a prn medication for pain.
d. Call radiology for a portable chest x-ray.
ANS: A
Preparation for implementation ensures efficient, safe, and effective nursing care;
the first activity is reassessment. The cause of the patient’s chest pain is unknown,
so the patient needs to be reassessed before pain medication is administered or a
chest x-ray is obtained. The nurse then notifies the patient’s health care provider of
the patient’s current condition in anticipation of receiving further orders. The
patient’s chest pain could be due to muscular injury or a pulmonary issue. The
nurse needs to reassess first.
4. A nurse is making initial rounds on patients. Which intervention for a patient
with poor wound healing should the nurse perform first?
a. Reinforce the wound dressing as needed with 4 × 4 gauze.
b. Perform the ordered dressing change twice daily.
c. Observe wound appearance and edges.
d. Document wound characteristics.
ANS: C
The most appropriate initial intervention is to assess the wound (observe wound
appearance and edges). The nurse must assess the wound first before the
findings can be documented, reinforcement of the dressing, and the actual skill
of dressing changes.
2
, 5. The nurse establishes trust and talks with a school-aged patient before
administering an injection. Which type of implementation skill is the nurse
using?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental
ANS: B
Nursing practice includes cognitive, interpersonal, and psychomotor skills.
Interpersonal skills involve developing trusting relationships with patients,
conveying caring and compassion, and communicating clearly. Cognitive
skills include critical thinking and decision-making skills. Psychomotor skill
requires the integration of cognitive and motor abilities, such as administering
the injection. Being judgmental is not appropriate in nursing; nurses are
nonjudgmental.
6. The nurse inserts an intravenous (IV) catheter using the correct technique
and following the recommended steps according to standards of care and
hospital policy. Which type of implementation skill is the nurse using?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental
ANS: C
Nursing practice includes cognitive, interpersonal, and psychomotor skills.
Psychomotor skill requires the integration of cognitive and motor abilities.
The nurse in this example displayed the psychomotor skill of inserting an
intravenous catheter while following standards of care and integrating
knowledge of anatomy and physiology. Cognitive involves the application of
critical thinking and use of good judgment in making sound clinical decisions.
Interpersonal skills involve developing trusting relationships with patients,
conveying caring and compassion, and communicating clearly.
7. A staff development nurse is providing an inservice for other nurses to
educate them about the Nursing Interventions Classification (NIC) system.
During the inservice, which statement made by one of the nurses in the room
requires the staff development nurse to clarify the information provided?
(Detail Solutions)
1. Which action should the nurse take first during the initial phase of
implementation?
a. Determine patient outcomes and goals.
b. Prioritize patient’s nursing diagnoses.
c. Evaluate interventions.
d. Reassess the patient.
ANS: D
Assessment is a continuous process that occurs each time the nurse interacts with
a patient. During the initial phase of implementation, reassess the patient.
Determining the patient’s goals and prioritizing diagnoses take place in the
planning phase before choosing interventions. Evaluation is the last step of the
nursing process.
2. Vital signs for a patient reveal a high blood pressure of 187/100. Orders
state to notify the health care provider for diastolic blood pressure greater than
90. What is the nurse’s first action?
a. Follow the clinical protocol for a stroke.
b. Review the most recent lab results for the
patient’s potassium level. Assess the patient
for other symptoms or problems, and then
notify the
c. health care provider.
Administer an antihypertensive medication from the stock supply, and
d. then notify the health care provider.
ANS: C
Communication to other health care professionals must be timely, accurate, and
relevant to a patient’s clinical situation. The best answer is to reassess the patient
for other symptoms or problems, and then notify the health care provider
according to the orders. Reviewing the potassium level does not address the
problem of high blood pressure. The nurse does not follow the protocol since the
order says to notify the health care provider. The orders read to notify the health
care provider, not administer medications.
1
,3. Which initial intervention is most appropriate for a patient who has a new onset
of chest pain?
a. Reassess the patient.
b. Notify the health care provider.
c. Administer a prn medication for pain.
d. Call radiology for a portable chest x-ray.
ANS: A
Preparation for implementation ensures efficient, safe, and effective nursing care;
the first activity is reassessment. The cause of the patient’s chest pain is unknown,
so the patient needs to be reassessed before pain medication is administered or a
chest x-ray is obtained. The nurse then notifies the patient’s health care provider of
the patient’s current condition in anticipation of receiving further orders. The
patient’s chest pain could be due to muscular injury or a pulmonary issue. The
nurse needs to reassess first.
4. A nurse is making initial rounds on patients. Which intervention for a patient
with poor wound healing should the nurse perform first?
a. Reinforce the wound dressing as needed with 4 × 4 gauze.
b. Perform the ordered dressing change twice daily.
c. Observe wound appearance and edges.
d. Document wound characteristics.
ANS: C
The most appropriate initial intervention is to assess the wound (observe wound
appearance and edges). The nurse must assess the wound first before the
findings can be documented, reinforcement of the dressing, and the actual skill
of dressing changes.
2
, 5. The nurse establishes trust and talks with a school-aged patient before
administering an injection. Which type of implementation skill is the nurse
using?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental
ANS: B
Nursing practice includes cognitive, interpersonal, and psychomotor skills.
Interpersonal skills involve developing trusting relationships with patients,
conveying caring and compassion, and communicating clearly. Cognitive
skills include critical thinking and decision-making skills. Psychomotor skill
requires the integration of cognitive and motor abilities, such as administering
the injection. Being judgmental is not appropriate in nursing; nurses are
nonjudgmental.
6. The nurse inserts an intravenous (IV) catheter using the correct technique
and following the recommended steps according to standards of care and
hospital policy. Which type of implementation skill is the nurse using?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental
ANS: C
Nursing practice includes cognitive, interpersonal, and psychomotor skills.
Psychomotor skill requires the integration of cognitive and motor abilities.
The nurse in this example displayed the psychomotor skill of inserting an
intravenous catheter while following standards of care and integrating
knowledge of anatomy and physiology. Cognitive involves the application of
critical thinking and use of good judgment in making sound clinical decisions.
Interpersonal skills involve developing trusting relationships with patients,
conveying caring and compassion, and communicating clearly.
7. A staff development nurse is providing an inservice for other nurses to
educate them about the Nursing Interventions Classification (NIC) system.
During the inservice, which statement made by one of the nurses in the room
requires the staff development nurse to clarify the information provided?
