ATI PN FUNDAMENTAL PROCTORED EXAM 2021

1. The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform? a. Dependent b. Independent c. Interdependent d. Physician-initiated ANS: C Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals. Health care provider-initiated (HCP) interventions are dependent nursing interventions, or actions that require an order from the HCP. Nurseinitiated interventions are the independent nursing interventions, or actions that a nurse initiates without supervision or direction from others. 2. A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing? a. Collaborative b. Independent c. Interdependent d. Dependent ANS: D The nurse does not have prescriptive authority to order pain medications, unless the nurse is an advanced practice nurse. The intervention is therefore dependent. Administering a medication, implementing an invasive procedure (e.g., inserting a 93 Foley catheter, starting an intravenous [IV] infusion), and preparing a patient for diagnostic tests are examples of health care provider-initiated interventions. A collaborative, or an interdependent, intervention involves therapies that require combined knowledge, skill, and expertise from multiple health care professionals. Nurse-initiated interventions are the independent nursing interventions, or actions that a nurse initiates without supervision or direction from others. 3. Which action indicates the nurse is using a PICOT question to improve care for a patient? a. Practices nursing based on the evidence presented in court b. Implements interventions based on scientific research c. Uses standardized care plans for all patients. d. Plans care based on tradition ANS: B The best answer is implementing interventions based on scientific research. Using results of a literature search to a PICOT question can help a nurse decide which interventions to use. Practicing based on evidence presented in court is incorrect. Practice is based on current research. Using standardized care plans may be one example of evidence-based practice, but it is not used on all patients. The nurse must be careful in using standardized care plans to ensure that each patient’s plan of care is still individualized. Planning care based on tradition is incorrect because nursing care should be based on current research. 4. A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication? a. Provide the patient with a writing board each shift. b. Obtain an interpreter for the patient as soon as possible. c. Assist the patient in performing swallowing exercises each shift. Ask the family to provide a sitter to remain with the patient at all d. times. 93 ANS: A Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. If the etiology is impaired verbal communication, then the nurse should choose an intervention that will address the problem. Providing the patient with a writing board will allow the patient to communicate by writing because the patient is unable to communicate verbally at this time. Obtaining an interpreter might be an appropriate intervention if the patient spoke a foreign language. Assisting with swallowing exercises will help the patient with swallowing, which is a different etiology than impaired verbal communication. Asking the family to provide a sitter at all times is many times unrealistic and does not relate to the impaired verbal communication; the goal would relate to the loneliness. 5. A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces? a. Administer pain medication every 4 hours as needed. b. Turn the patient every 2 hours, even hours. c. Monitor vital signs, especially rhythm. d. Keep the bed side rails up at all times. ANS: B The most appropriate intervention for the diagnosis of Impaired skin integrity is to turn the patient. Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. The other options do not directly address the shearing forces. The patient may need pain medication, but Acute pain would be another nursing diagnosis. Monitoring vital signs does not have when or how often these should be done. Keeping the side rails up addresses safety, not skin integrity. 6. A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls? a. Keep all side rails down at all times. b. Encourage patient to remain in bed most of the shift.