ATI PN FUNDAMENTALS LATEST TEST BANK REAL EXAM (2023-
2024) COMPLETE ACCURATE EXAM QUESTIONS WITH
DETAILED VERIFIED ANSWERS (100% CORRECT ANSWERS)
/ALREADY GRADED A+!!.
ATI PN
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? - - ANS
- -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 the wound change as
performed.
. 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? - - ANS - -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?
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. - - ANS - -A) Asking about pain during vital signs
Which factor in the patient's past medical history dictates that the nurse exercise
caution when administering acetaminophen (Tylenol)? - - ANS - -A) Hepatitis B
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.
Which action should the nurse take before administering morphine 4.0 mg
intravenously to a patient complaining of incisional pain? - - ANS - -Assess the
patient's respiratory status.
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. Downloaded by: spazzoutent | brandonjmecusker
,Which action should the nurse take when preparing patient-controlled analgesia for a
postoperative patient? - - ANS - -ask another nurse to double check the setup patient
use
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.
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? - - ANS - -in 60 minutes
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.
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet
aggregation in a patient at risk for thrombophlebitis? - - ANS - -Aspirin (Ecotrin)
: 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.
, 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? - - ANS - -C) Epidural catheter migration
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.
Which of the following clients is experiencing an abnormal change in vital signs? A
client whose - - ANS - -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
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.
The nurse assesses clients' breath sounds. Which one requires immediate medical
attention? A client who has: - - ANS - -Stridor
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.
2024) COMPLETE ACCURATE EXAM QUESTIONS WITH
DETAILED VERIFIED ANSWERS (100% CORRECT ANSWERS)
/ALREADY GRADED A+!!.
ATI PN
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? - - ANS
- -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 the wound change as
performed.
. 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? - - ANS - -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?
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. - - ANS - -A) Asking about pain during vital signs
Which factor in the patient's past medical history dictates that the nurse exercise
caution when administering acetaminophen (Tylenol)? - - ANS - -A) Hepatitis B
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.
Which action should the nurse take before administering morphine 4.0 mg
intravenously to a patient complaining of incisional pain? - - ANS - -Assess the
patient's respiratory status.
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. Downloaded by: spazzoutent | brandonjmecusker
,Which action should the nurse take when preparing patient-controlled analgesia for a
postoperative patient? - - ANS - -ask another nurse to double check the setup patient
use
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.
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? - - ANS - -in 60 minutes
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.
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet
aggregation in a patient at risk for thrombophlebitis? - - ANS - -Aspirin (Ecotrin)
: 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.
, 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? - - ANS - -C) Epidural catheter migration
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.
Which of the following clients is experiencing an abnormal change in vital signs? A
client whose - - ANS - -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
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.
The nurse assesses clients' breath sounds. Which one requires immediate medical
attention? A client who has: - - ANS - -Stridor
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.
