ATI PN 112 Final Exam 12/25
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Free ATI PN 112 Final Exam 12/25 Questions
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- Allow the family to view the body privately.
- Have a clergy member present when the family first sees the client.
- Ask the family to return after the staff cleans the body.
- Perform postmortem care so that the body is prepared for the funeral home.
Explanation
Explanation
When a client dies unexpectedly, the priority is to support the family’s immediate grieving needs. Allowing the family to view the body privately promotes emotional expression, closure, and respects cultural and personal grieving practices. Postmortem care and involvement of clergy should be offered after the family has had an opportunity to see the client, not before. Delaying access to the body can increase distress and is not therapeutic.Correct Answer Is:
A. Allow the family to view the body privately.Nurses' Notes
Yesterday:
0800:
Client reports a "deep and severe pain in my right shoulder". Client states it is a burning pain that starts in the shoulder and radiates to the spine. Client has taken ibuprofen and it hasn't helped the pain. Client is grimacing and leaning forward. Heart rate is regular. Lungs are clear to auscultation. Client has no abdominal distention or tenderness. Bowel sounds are normoactive. Client has full range of motion of right shoulder. Rates pain as 8 on scale of 0 to 10. Skin has several grouped vesicles on an erythematous base from the right shoulder to the spine.
Diagnostic Results
Day 1:
0845:
Right shoulder x-ray: no fracture or dislocation. No acute abnormalities.
Vital Signs
Day 10800:
Temperature 37.2 C (98.9 °F)
Respiratory rate 18/min
Heart rate 89/min
A nurse is caring for a client in a provider's office.
What condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
-
Condition: Cellulitis
Actions: Prepare the client for outpatient IV antibiotic therapy; Request a prescription for a topical corticosteroid
Parameters to monitor: Broken area of skin; Pruritus on hands, elbows, and neck -
Condition: Herpes simplex virus type 2
Actions: Instruct the client about safe-sex practices; Administer an antihistamine and antiviral medication
Parameters to monitor: Vesicles on genitalia; Pain -
Condition: Herpes zoster (shingles)
Actions: Request a prescription for analgesic medication; Administer an antiviral medication
Parameters to monitor: Pain; Post-herpetic neuralgia -
Condition: Atopic dermatitis
Actions: Request a prescription for a topical corticosteroid; Administer an antihistamine
Parameters to monitor: Pruritus on hands, elbows, and neck; Broken area of skin
Explanation
Explanation
The client’s symptoms are most consistent with herpes zoster (shingles), as indicated by severe, burning neuropathic pain radiating along a dermatomal pattern and the presence of grouped vesicles on an erythematous base extending from the shoulder to the spine. Management focuses on controlling pain with appropriate analgesics and limiting viral replication through antiviral therapy to reduce symptom duration and complications. Monitoring pain evaluates treatment effectiveness, while monitoring for post-herpetic neuralgia is essential because persistent nerve pain is a common and serious complication of shingles.Correct Answer Is:
C. Condition: Herpes zoster (shingles); Actions: Request a prescription for analgesic medication and administer an antiviral medication; Parameters to monitor: Pain and post-herpetic neuralgiaA nurse is collecting data from a client who is experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?
- Concave curving of fingernail beds
- PaO₂ 99 mm Hg
- Decreased anterior-posterior chest diameter
- PaCO₂ 48 mm Hg
Explanation
Explanation
During an acute exacerbation of COPD, impaired ventilation leads to carbon dioxide retention. This results in an elevated PaCO₂ level, a condition known as hypercapnia. A PaCO₂ of 48 mm Hg is above the normal range and reflects inadequate alveolar ventilation. The other findings are inconsistent with COPD exacerbation, as clients typically have hypoxemia, an increased anterior-posterior chest diameter, and clubbing rather than concave nail beds.Correct Answer Is:
D. PaCO₂ 48 mm HgA nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
- BP 146/94 mm Hg
- Bounding pulse
- Distended neck veins
- Urine specific gravity 1.034
Explanation
Explanation
Dehydration causes the kidneys to conserve water, resulting in concentrated urine. This leads to an elevated urine specific gravity above the normal range of approximately 1.005 to 1.030. A value of 1.034 indicates significant fluid deficit. The other findings suggest fluid overload rather than dehydration, making increased urine concentration the most reliable indicator.Correct Answer Is:
D. Urine specific gravity 1.034A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- Dyspnea
- Frothy sputum
- Peripheral edema
- Orthopnea
Explanation
Explanation
Right-sided heart failure leads to impaired pumping of blood into the pulmonary circulation, causing blood to back up into the systemic venous system. This results in fluid accumulation in dependent areas of the body, most commonly presenting as peripheral edema in the lower extremities. Other common findings may include jugular venous distention, hepatomegaly, ascites, and weight gain due to fluid retention.Correct Answer Is:
C. Peripheral edemaA nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
- Call the family and ask them to make arrangements for someone to sit with the client.
- Assist the client back into bed and apply restraints.
- Check the client for injuries.
- Obtain a prescription for medication to sedate the client.
Explanation
Explanation
When a client is found on the floor, the priority action is assessment. The nurse must first check for injuries, including head trauma, fractures, bleeding, pain, or changes in level of consciousness, before moving the client. Immediate repositioning, restraint use, sedation, or contacting family without assessment could worsen an undetected injury. A thorough injury assessment ensures client safety and guides appropriate follow-up interventions.Correct Answer Is:
C. Check the client for injuries.A nurse is collecting data on a newly admitted client to the emergency room. Using the ABCDE format for data collection, which of the following areas are reviewed under the “C” category?
- Oxygen saturation and respiratory rate
- Response to voice and pain
- Heart and blood vessels
- Mouth, larynx, and bronchi
Explanation
Explanation
In the ABCDE assessment framework, C stands for Circulation. This category focuses on evaluating the cardiovascular system, including heart rate, blood pressure, capillary refill, skin color and temperature, and signs of bleeding or poor perfusion. Assessing circulation helps identify life-threatening issues such as shock, hemorrhage, or cardiac dysfunction that require immediate intervention.Correct Answer Is:
C. Heart and blood vesselsA nurse is teaching a class to new staff members about the importance of a positive work environment. Which of the following could be used as an example of professional comportment?
- Completing all care tasks before the end of the shift
- Postponing documentation in the medical record
- Staff members socializing at the nurse’s station
- Collaboration among staff to complete tasks
Explanation
Explanation
Professional comportment refers to behaviors that promote respect, teamwork, and high-quality client care. Collaboration among staff demonstrates professionalism by fostering effective communication, shared responsibility, and mutual support. This approach enhances efficiency, reduces errors, and contributes to a positive work environment. Socializing at the nurse’s station and delaying documentation are unprofessional behaviors, and simply completing tasks does not fully reflect professional interaction.Correct Answer Is:
D. Collaboration among staff to complete tasksA nurse is preparing to administer an ophthalmic solution to a client. Which of the following actions should the nurse take?
- Bring the dropper from below the client’s eye to instill the solution.
- Instill the drops into the inner canthus.
- Ask the client to look down when instilling the solution.
- Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac.
Explanation
Explanation
When administering ophthalmic medications, the nurse should pull down the lower eyelid to expose the conjunctival sac and hold the dropper approximately 1 to 2 cm above it. This technique prevents contamination of the dropper tip and ensures accurate delivery of the medication into the conjunctival sac, where it can be absorbed effectively. The client should be instructed to look upward, not downward, during instillation.Correct Answer Is:
D. Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac.A nurse is caring for a client in a provider's office.
Nurses' Notes
Yesterday:
0800:
Client reports a "deep and severe pain in my right shoulder". Client states it is a burning pain that starts in the shoulder and radiates to the spine. Client has taken ibuprofen and it hasn't helped the pain. Client is grimacing and leaning forward. Heart rate is regular. Lungs are clear to auscultation. Client has no abdominal distention or tenderness. Bowel sounds are normoactive. Client has full range of motion of right shoulder. Rates pain as 8 on scale of 0 to 10. Skin has several grouped vesicles on an erythematous base from the right shoulder to the spine.
Diagnostic Results
Day 1:
0845:
Right shoulder x-ray: no fracture or dislocation. No acute abnormalities.
Vital Signs
Day 10800:
Temperature 37.2 C (98.9 °F)
Respiratory rate 18/min
Heart rate 89/min
What condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
-
Condition: Cellulitis
Actions: Prepare the client for outpatient IV antibiotic therapy; Request a prescription for a topical corticosteroid
Parameters to monitor: Broken area of skin; Pruritus on hands, elbows, and neck -
Condition: Herpes simplex virus type 2
Actions: Instruct the client about safe-sex practices; Administer an antihistamine and antiviral medication
Parameters to monitor: Vesicles on genitalia; Pain -
Condition: Herpes zoster (shingles)
Actions: Request a prescription for analgesic medication; Administer an antiviral medication
Parameters to monitor: Pain; Post-herpetic neuralgia -
Condition: Atopic dermatitis
Actions: Request a prescription for a topical corticosteroid; Administer an antihistamine
Parameters to monitor: Pruritus on hands, elbows, and neck; Broken area of skin
Explanation
Explanation
The client’s symptoms are most consistent with herpes zoster (shingles), as indicated by severe, burning neuropathic pain radiating along a dermatomal pattern and the presence of grouped vesicles on an erythematous base extending from the shoulder to the spine. Management focuses on controlling pain with appropriate analgesics and limiting viral replication through antiviral therapy to reduce symptom duration and complications. Monitoring pain evaluates treatment effectiveness, while monitoring for post-herpetic neuralgia is essential because persistent nerve pain is a common and serious complication of shingles.Correct Answer Is:
C. Condition: Herpes zoster (shingles); Actions: Request a prescription for analgesic medication and administer an antiviral medication; Parameters to monitor: Pain and post-herpetic neuralgiaHow to Order
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