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.