ATI PN Fundamentals 2023

ATI PN Fundamentals 2023 Related

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Nurses' Notes
Vital Signs
Diagnostic Results
6 months ago:

Client present today for annual examination. Reports lack of sleep and increased stress due to moving and starting a new job.

Today, 1400:

Client presents to office today with reports of fatigue. Client states they have difficulty sleeping without drinking four or five beers a night. Client reports, "I sometimes get headaches along with nausea and vomiting. I have been busy with my new job, so I have been eating a lot of fast food, and I've gained 15 pounds."

Today, 1445.

Provider notified of laboratory results.

A nurse is assisting in the care of a client in a provider's office. A nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?

  • A. Administer a diuretic.
  • B. Limit alcohol intake to 2 drinks per day.
  • C. Keep daily fat intake to less than 35%
  • D. Place on 2300 mg sodium diet.
  • E. Administer an antibiotic
  • F. Limit foods high in potassium.
Correct Answer: A, B, C, D

Rationale: A: Addresses fluid retention from fast food. B, C, D: Manage weight gain and hypertension risks.

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A nurse is assisting with developing a plan of care for a client.

Exhibit 1

Nurses' Notes
2 days ago:

Client admitted to telemetry unit for uncontrolled atrial fibrillation. Admission skin assessment, area of intact, blanchable skin on client's coccyx.

Today, 0900:

Wound on client's coccyx no longer covered with intact skin. Wound involves full-thickness skin loss, shallow depth with no tunneling. New granulation noted. Minimal amount of exudate noted. Client reports wound pain as 5 on a scale of 0 to 10 and is unable to find a comfortable position.

Complete the following sentence by using the lists of options. The nurse understands that which of the following dressing should be added to the plan of care

  • A. hydrocolloid
  • B. dry gauze
  • C. hydrogel
  • D. alginate
  • E. transparent
Correct Answer: A

Rationale: Hydrocolloid dressings promote healing in full-thickness wounds with minimal exudate.

A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

  • A. Place the specimen in a clean specimen cup.
  • B. Clamp the catheter tubing below the needleless port.
  • C. Clamp the catheter tubing for 60 min.
  • D. Remove 45 mL of urine from the catheter with a syringe.
Correct Answer: B

Rationale: Clamping below the port allows fresh urine to collect for an accurate culture.

A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?

  • A. We will use an electric blanket to keep your partner warm.
  • B. Encourage your partner to eat three large meals each day.
  • C. Assume your partner can hear you, even if they do not respond.
  • D. Opioids will be restricted if your partner develops respiratory distress.
Correct Answer: C

Rationale: Assuming hearing persists respects dignity and encourages communication in end-of-life care.

A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?

  • A. Make sure four fingers fit between the restraint and the client's body.
  • B. Apply the belt restraint over the client's gown.
  • C. Check the client's skin integrity every 4 hr.
  • D. Tie the belt restraint to the side rail of the bed.
Correct Answer: B

Rationale: Applying over the gown prevents skin irritation and ensures proper fit.

A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?

  • A. Don't worry. Everything will work out for you.
  • B. Your quality of life will be compromised if you make this decision.
  • C. We should talk about your decision later.
  • D. How will you discuss this decision with your loved ones?
Correct Answer: D

Rationale: This response supports the client's autonomy and encourages communication.

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