ATI EXAM vc
Exam Solution vc
Prioritization Delegation & Assignment NCLEX Cartes 2 vc vc vc vc vc vc
026 A+ GRADE ASSURED COMPLETE SOLUTIONS AND V
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ERIFIED ANSWERS (46EDC) vc vc
QUESTION 1 vc
Ans: 4 As charge nurse, you must assess the performance and attitude of the staff in relat
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ion to this client. After data are gathered from the nurses, additional information can be
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obtained from the records and the client as necessary. The educator may be of assistance
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if a knowledge deficit or need for performance improvement is the problem. Focus: Sup
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ervision, prioritization vc
ANSWER
You are the charge nurse. A client with chronic pain reports to you that the nurses have not been respo
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nding to requests for pain medication. What is your initial action? 1. Check the medication administratio
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n records (MARs) for the past several days. 2. Ask the nurse educator to provide in-
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service training about pain management. 3. Perform a complete pain assessment on the client and take
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a pain history. 4. Have a conference with the nurses responsible for the care of this client.
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QUESTION 2 vc
Ans: 3 Beliefs, attitudes, & familial influence are part of the sociocultural dimension of p
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ain. Location and radiation of pain address the sensory dimension. Describing pain & its
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effects addresses the affective dimension. Activity level and function address the behavio
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ral dimension. Asking about knowledge addresses cognitive dimension. Focus: Prioritiza
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tion 3. vc
ANSWER
Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to
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narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the cu
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rrent priority for the client. Which question will you ask? 1. " Where is the pain located, & does it radiat
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e to other parts of your body?" 2. " How would you describe the pain, and how is it affecting you?" 3. "
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What do you believe about pain medication and drug addiction?" 4. " How is the pain affecting your acti
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vity level and your ability to function?" 5. " What information do you need about pain, healing, and addi
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ction?"
,QUESTION 3 vc
Ans: 1 Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropath
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y. Corticosteroids are for pain associated with inflammation. Hydromorphone is a strong
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er opioid, and it is not the first choice for chronic pain that can be managed with other d
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rugs. Lorazepam is an anxiolytic that may be ordered as an adjuvant Medication. Focus:
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Prioritization
ANSWER
A client with diabetic neuropathy reports a burning, electrical-
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type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-
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inflammatory drugs. Which medication will you advocate for first? 1. Gabapentin (Neurontin) 2. Corticos
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teroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan)
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QUESTION 4 vc
Ans: 3 Cancer pain generally worsens with disease progression, & the use of opioids is m
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ore generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant me
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dications. Trigeminal neuralgia is treated with antiseizure medications such as carbama
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zepine (Tegretol). Phantom limb pain usually subsides after ambulation begins. Focus: P
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rioritization
ANSWER
Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia
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2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client w
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ith trigeminal neuralgia
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QUESTION 5 vc
Ans: 1 Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the
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nurse to observe response to treatments and to help the patient deal with loss or anxiety
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. The UAP can be directed to weigh the patient but should not be expected to know when
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to initiate that measurement. Focus: Delegation
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ANSWER
You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? 1. Assistin
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g the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression
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of grief or anxiety 4. Initiating daily weighings
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QUESTION 6 vc
Ans: 4 The patient's physical condition is currently stable, but emotional needs are affect
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ing his or her ability to receive the information required to make an informed decision.
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, The other diagnoses are relevant, but if the patient leaves the clinic the interventions ma
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y be delayed or ignored. Focus: Prioritization
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ANSWER
2. A 56-year-old patient comes to the walk-
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in clinic reporting scant rectal bleeding and intermittent diarrhea & constipation for past several month
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s. There is a history of polyps & family history of colorectal cancer. While you are trying to teach about
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colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis? 1. Diarrh
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ea/ Constipation related to altered bowel patterns 2. Deficient Knowledge related to the disease process
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& diagnostic procedure 3. Risk for Deficient Fluid Volume related to rectal bleeding and diarrhea 4. Anx
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iety related to unknown outcomes & perceived threats to body integrity
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QUESTION 7 vc
Ans: 1 Pancreatic cancer more common African-
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Americans, males, & smokers. Other associated factors include alcohol use, diabetes, obe
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sity, history of pancreatitis, exposure to organic chemicals, consumption of a high-
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fat diet, & previous abdominal irradiation. Focus: Prioritization
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ANSWER
Which patient is at greatest risk for pancreatic cancer? 1. An elderly African-
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American man who smokes 2. Young white obese woman with gallbladder disease 3. A young African-
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American man with type 1 diabetes 4. An elderly white woman who has pancreatitis
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QUESTION 8 vc
Ans: 2, 3, 5, 6, 7 Mouthwash should not include alcohol, because it has drying action that
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leaves mucous membranes more vulnerable. Insertion of suppositories, probes, or tamp
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ons into the rectal or vaginal cavity is not recommended. All other options are appropria
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te. Focus: Prioritization, knowledge
vc vc vc
ANSWER
Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease p
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rocesses. Which actions are needed for patients who must be placed on bleeding precautions? (Select all
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that apply.) 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Pro
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vide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-
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containing products. 6. Avoid overinflation of blood pressure cuffs. 7. Pad sharp corners of furniture.
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QUESTION 9 vc
Ans: 2 Administering enemas & antibiotics is within the scope of practice of LPNs/ LVNs.
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Although some states an facilities may allow LPN/ LVN to administer blood, in general, a
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dministering blood, providing preoperative teaching, & assisting with central line inserti
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on are responsibilities of RN. Focus: Assignment
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ANSWER
Exam Solution vc
Prioritization Delegation & Assignment NCLEX Cartes 2 vc vc vc vc vc vc
026 A+ GRADE ASSURED COMPLETE SOLUTIONS AND V
vc vc vc vc vc vc vc
ERIFIED ANSWERS (46EDC) vc vc
QUESTION 1 vc
Ans: 4 As charge nurse, you must assess the performance and attitude of the staff in relat
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ion to this client. After data are gathered from the nurses, additional information can be
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
obtained from the records and the client as necessary. The educator may be of assistance
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if a knowledge deficit or need for performance improvement is the problem. Focus: Sup
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ervision, prioritization vc
ANSWER
You are the charge nurse. A client with chronic pain reports to you that the nurses have not been respo
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
nding to requests for pain medication. What is your initial action? 1. Check the medication administratio
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
n records (MARs) for the past several days. 2. Ask the nurse educator to provide in-
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
service training about pain management. 3. Perform a complete pain assessment on the client and take
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
a pain history. 4. Have a conference with the nurses responsible for the care of this client.
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
QUESTION 2 vc
Ans: 3 Beliefs, attitudes, & familial influence are part of the sociocultural dimension of p
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ain. Location and radiation of pain address the sensory dimension. Describing pain & its
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effects addresses the affective dimension. Activity level and function address the behavio
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ral dimension. Asking about knowledge addresses cognitive dimension. Focus: Prioritiza
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tion 3. vc
ANSWER
Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the cu
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
rrent priority for the client. Which question will you ask? 1. " Where is the pain located, & does it radiat
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
e to other parts of your body?" 2. " How would you describe the pain, and how is it affecting you?" 3. "
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What do you believe about pain medication and drug addiction?" 4. " How is the pain affecting your acti
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vity level and your ability to function?" 5. " What information do you need about pain, healing, and addi
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ction?"
,QUESTION 3 vc
Ans: 1 Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropath
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
y. Corticosteroids are for pain associated with inflammation. Hydromorphone is a strong
vc vc vc vc vc vc vc vc vc vc vc
er opioid, and it is not the first choice for chronic pain that can be managed with other d
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
rugs. Lorazepam is an anxiolytic that may be ordered as an adjuvant Medication. Focus:
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Prioritization
ANSWER
A client with diabetic neuropathy reports a burning, electrical-
vc vc vc vc vc vc vc vc
type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
inflammatory drugs. Which medication will you advocate for first? 1. Gabapentin (Neurontin) 2. Corticos
vc vc vc vc vc vc vc vc vc vc vc vc vc
teroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan)
vc vc vc vc vc vc
QUESTION 4 vc
Ans: 3 Cancer pain generally worsens with disease progression, & the use of opioids is m
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ore generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant me
vc vc vc vc vc vc vc vc vc vc vc vc vc
dications. Trigeminal neuralgia is treated with antiseizure medications such as carbama
vc vc vc vc vc vc vc vc vc vc
zepine (Tegretol). Phantom limb pain usually subsides after ambulation begins. Focus: P
vc vc vc vc vc vc vc vc vc vc vc
rioritization
ANSWER
Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client w
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ith trigeminal neuralgia
vc vc
QUESTION 5 vc
Ans: 1 Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
nurse to observe response to treatments and to help the patient deal with loss or anxiety
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
. The UAP can be directed to weigh the patient but should not be expected to know when
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
to initiate that measurement. Focus: Delegation
vc vc vc vc vc
ANSWER
You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? 1. Assistin
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
g the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
of grief or anxiety 4. Initiating daily weighings
vc vc vc vc vc vc vc
QUESTION 6 vc
Ans: 4 The patient's physical condition is currently stable, but emotional needs are affect
vc vc vc vc vc vc vc vc vc vc vc vc vc
ing his or her ability to receive the information required to make an informed decision.
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
, The other diagnoses are relevant, but if the patient leaves the clinic the interventions ma
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
y be delayed or ignored. Focus: Prioritization
vc vc vc vc vc vc
ANSWER
2. A 56-year-old patient comes to the walk-
vc vc vc vc vc vc vc
in clinic reporting scant rectal bleeding and intermittent diarrhea & constipation for past several month
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
s. There is a history of polyps & family history of colorectal cancer. While you are trying to teach about
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis? 1. Diarrh
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ea/ Constipation related to altered bowel patterns 2. Deficient Knowledge related to the disease process
vc vc vc vc vc vc vc vc vc vc vc vc vc vc v
& diagnostic procedure 3. Risk for Deficient Fluid Volume related to rectal bleeding and diarrhea 4. Anx
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iety related to unknown outcomes & perceived threats to body integrity
vc vc vc vc vc vc vc vc vc vc
QUESTION 7 vc
Ans: 1 Pancreatic cancer more common African-
vc vc vc vc vc vc
Americans, males, & smokers. Other associated factors include alcohol use, diabetes, obe
vc vc vc vc vc vc vc vc vc vc vc
sity, history of pancreatitis, exposure to organic chemicals, consumption of a high-
vc vc vc vc vc vc vc vc vc vc vc
fat diet, & previous abdominal irradiation. Focus: Prioritization
vc vc vc vc vc vc vc
ANSWER
Which patient is at greatest risk for pancreatic cancer? 1. An elderly African-
vc vc vc vc vc vc vc vc vc vc vc vc
American man who smokes 2. Young white obese woman with gallbladder disease 3. A young African-
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
American man with type 1 diabetes 4. An elderly white woman who has pancreatitis
vc vc vc vc vc vc vc vc vc vc vc vc vc
QUESTION 8 vc
Ans: 2, 3, 5, 6, 7 Mouthwash should not include alcohol, because it has drying action that
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
leaves mucous membranes more vulnerable. Insertion of suppositories, probes, or tamp
vc vc vc vc vc vc vc vc vc vc
ons into the rectal or vaginal cavity is not recommended. All other options are appropria
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
te. Focus: Prioritization, knowledge
vc vc vc
ANSWER
Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease p
vc vc vc vc vc vc vc vc vc vc vc vc vc
rocesses. Which actions are needed for patients who must be placed on bleeding precautions? (Select all
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
that apply.) 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Pro
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
vide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
containing products. 6. Avoid overinflation of blood pressure cuffs. 7. Pad sharp corners of furniture.
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
QUESTION 9 vc
Ans: 2 Administering enemas & antibiotics is within the scope of practice of LPNs/ LVNs.
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
Although some states an facilities may allow LPN/ LVN to administer blood, in general, a
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
dministering blood, providing preoperative teaching, & assisting with central line inserti
vc vc vc vc vc vc vc vc vc vc
on are responsibilities of RN. Focus: Assignment
vc vc vc vc vc vc
ANSWER
