ATI PN PHARMACOLOGY PROCTORED COMPLETE SOLUTION
(Detail Solutions)
1. A nurse is providing nursing care to patients after completing a care
plan from nursing diagnoses. In which step of the nursing process is the
nurse?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
ANS: C
Implementation, the fourth step of the nursing process, formally begins after a
nurse develops a plan of care. With a care plan based on clear and relevant
nursing diagnoses, a nurse initiates interventions that are designed to assist the
patient in achieving the goals and expected outcomes needed to support or
improve the patient’s health status. The nurse gathers data during the
assessment phase and mutually sets goals and prioritizes care during the
planning phase. During the evaluation phase, the nurse determines the
achievement of goals and effectiveness of interventions.
2. The nurse is teaching a new nurse about protocols. Which
information from the new nurse indicates a correct understanding of the
teaching?
a. Protocols are guidelines to follow that replace the nursing care plan.
Protocols assist the clinician in making decisions and choosing
b. interventions for specific health care problems or conditions.
Protocols are policies designating each nurse’s duty according to
c. standards of care and a code of ethics.
Protocols are prescriptive order forms that help individualize the plan
d. of care.
ANS: B
A clinical practice guideline or protocol is a systematically developed set of
statements that helps nurses, physicians, and other health care providers make
decisions about appropriate health care for specific clinical situations. This
guideline establishes interventions for specific health care problems or
conditions. The protocol does not replace the nursing care plan. Evidence-
based guidelines from protocols can be incorporated into an individualized
plan of care. A clinical guideline is not the same as a hospital policy. Standing
1
orders contain orders for the care of a specific group of patients. A protocol is
not a prescriptive order form like a standing order.
,3. The standing orders for a patient include acetaminophen 650 mg every
4 hours prn for headache. After assessing the patient, the nurse identifies the
need for headache relief and determines that the patient has not had
acetaminophen in the past 4 hours. Which action will the nurse take next?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
c. Direct the nursing assistive
personnel to give the
acetaminophen. Perform a pain
assessment only after administering
the
d. acetaminophen.
ANS: A
A standing order is a preprinted document containing orders for the conduct
of routine therapies, monitoring guidelines, and/or diagnostic procedures for
specific patients with identified clinical problems. The nurse will administer
the medication. Notifying the health care provider is not necessary if a
standing order exists. The nursing assistive personnel are not licensed to
administer medications; therefore, medication administration should not be
delegated to this person. A pain assessment should be performed before and
after pain medication administration to assess the need for and effectiveness
of the medication.
4. Which action indicates a nurse is using critical thinking for
implementation of nursing care to patients?
Determines whether an intervention is correct and appropriate for the
a. given situation
Reads over the steps and performs a procedure despite lack of clinical
b. competency
c. Establishes goals for a particular patient without assessment
d. Evaluates the effectiveness of interventions
ANS: A
As you implement interventions, use critical thinking to confirm whether the
interventions are correct and still appropriate for a patient’s clinical situation.
You are responsible for having the necessary knowledge and clinical
competency to perform interventions for your patients safely and effectively.
The nurse needs to recognize the safety hazards of performing an intervention
without clinical competency and seek assistance from another nurse. The
nurse cannot evaluate interventions until they are implemented. Patients need 2
ongoing assessment before establishing goals because patient conditions can
, change very rapidly.
5. A nurse is reviewing a patient’s care plan. Which information
will the nurse identify as a nursing intervention?
The patient will ambulate in the hallway twice this shift using crutches
a. correctly.
Impaired physical mobility related to inability to bear weight on right
b. leg.
Provide assistance while the patient walks in the hallway twice this
c. shift with crutches.
d. The patient is unable to bear weight on right lower extremity.
ANS: C
Providing assistance to a patient who is ambulating is a nursing intervention.
The statement, “The patient will ambulate in the hallway twice this shift using
crutches correctly” is a patient outcome. Impaired physical mobilityis a nursing
diagnosis. The statement that the patient is unable to bear weight and ambulate
can be included with assessment data and is a defining characteristic for the
diagnosis of Impaired physical mobility.
6. A patient recovering from a leg fracture after a fall reports having dull
pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not
able to walk around in the room with crutches because of leg discomfort.
Which nursing intervention is priority?
a. Assist the patient to walk in the room with crutches.
b. Obtain a walker for the patient.
c. Consult physical therapy.
d. Administer pain medication.
ANS: D
The patient’s pain is a 7, indicating the priority is pain relief (administer pain
medication). Acute pain is the priority because the nurse can address the
problem of immobility after the patient receives adequate pain relief. Assisting
the patient to walk or obtaining a walker will not address the pain the patient
is experiencing.
7. The nurse is caring for a patient who requires a complex dressing
change. While in the patient’s room, the nurse decides to change the
dressing. Which action will the nurse take just before changing the
dressing?
a. Gathers and organizes needed supplies
3
b. Decides on goals and outcomes for the patient
(Detail Solutions)
1. A nurse is providing nursing care to patients after completing a care
plan from nursing diagnoses. In which step of the nursing process is the
nurse?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
ANS: C
Implementation, the fourth step of the nursing process, formally begins after a
nurse develops a plan of care. With a care plan based on clear and relevant
nursing diagnoses, a nurse initiates interventions that are designed to assist the
patient in achieving the goals and expected outcomes needed to support or
improve the patient’s health status. The nurse gathers data during the
assessment phase and mutually sets goals and prioritizes care during the
planning phase. During the evaluation phase, the nurse determines the
achievement of goals and effectiveness of interventions.
2. The nurse is teaching a new nurse about protocols. Which
information from the new nurse indicates a correct understanding of the
teaching?
a. Protocols are guidelines to follow that replace the nursing care plan.
Protocols assist the clinician in making decisions and choosing
b. interventions for specific health care problems or conditions.
Protocols are policies designating each nurse’s duty according to
c. standards of care and a code of ethics.
Protocols are prescriptive order forms that help individualize the plan
d. of care.
ANS: B
A clinical practice guideline or protocol is a systematically developed set of
statements that helps nurses, physicians, and other health care providers make
decisions about appropriate health care for specific clinical situations. This
guideline establishes interventions for specific health care problems or
conditions. The protocol does not replace the nursing care plan. Evidence-
based guidelines from protocols can be incorporated into an individualized
plan of care. A clinical guideline is not the same as a hospital policy. Standing
1
orders contain orders for the care of a specific group of patients. A protocol is
not a prescriptive order form like a standing order.
,3. The standing orders for a patient include acetaminophen 650 mg every
4 hours prn for headache. After assessing the patient, the nurse identifies the
need for headache relief and determines that the patient has not had
acetaminophen in the past 4 hours. Which action will the nurse take next?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
c. Direct the nursing assistive
personnel to give the
acetaminophen. Perform a pain
assessment only after administering
the
d. acetaminophen.
ANS: A
A standing order is a preprinted document containing orders for the conduct
of routine therapies, monitoring guidelines, and/or diagnostic procedures for
specific patients with identified clinical problems. The nurse will administer
the medication. Notifying the health care provider is not necessary if a
standing order exists. The nursing assistive personnel are not licensed to
administer medications; therefore, medication administration should not be
delegated to this person. A pain assessment should be performed before and
after pain medication administration to assess the need for and effectiveness
of the medication.
4. Which action indicates a nurse is using critical thinking for
implementation of nursing care to patients?
Determines whether an intervention is correct and appropriate for the
a. given situation
Reads over the steps and performs a procedure despite lack of clinical
b. competency
c. Establishes goals for a particular patient without assessment
d. Evaluates the effectiveness of interventions
ANS: A
As you implement interventions, use critical thinking to confirm whether the
interventions are correct and still appropriate for a patient’s clinical situation.
You are responsible for having the necessary knowledge and clinical
competency to perform interventions for your patients safely and effectively.
The nurse needs to recognize the safety hazards of performing an intervention
without clinical competency and seek assistance from another nurse. The
nurse cannot evaluate interventions until they are implemented. Patients need 2
ongoing assessment before establishing goals because patient conditions can
, change very rapidly.
5. A nurse is reviewing a patient’s care plan. Which information
will the nurse identify as a nursing intervention?
The patient will ambulate in the hallway twice this shift using crutches
a. correctly.
Impaired physical mobility related to inability to bear weight on right
b. leg.
Provide assistance while the patient walks in the hallway twice this
c. shift with crutches.
d. The patient is unable to bear weight on right lower extremity.
ANS: C
Providing assistance to a patient who is ambulating is a nursing intervention.
The statement, “The patient will ambulate in the hallway twice this shift using
crutches correctly” is a patient outcome. Impaired physical mobilityis a nursing
diagnosis. The statement that the patient is unable to bear weight and ambulate
can be included with assessment data and is a defining characteristic for the
diagnosis of Impaired physical mobility.
6. A patient recovering from a leg fracture after a fall reports having dull
pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not
able to walk around in the room with crutches because of leg discomfort.
Which nursing intervention is priority?
a. Assist the patient to walk in the room with crutches.
b. Obtain a walker for the patient.
c. Consult physical therapy.
d. Administer pain medication.
ANS: D
The patient’s pain is a 7, indicating the priority is pain relief (administer pain
medication). Acute pain is the priority because the nurse can address the
problem of immobility after the patient receives adequate pain relief. Assisting
the patient to walk or obtaining a walker will not address the pain the patient
is experiencing.
7. The nurse is caring for a patient who requires a complex dressing
change. While in the patient’s room, the nurse decides to change the
dressing. Which action will the nurse take just before changing the
dressing?
a. Gathers and organizes needed supplies
3
b. Decides on goals and outcomes for the patient
