ATI Fundamentals Proctored Exam Study Guide 3 -Nurselytic

Correct Answer: B

Rationale: The correct answer is B: RN. The Registered Nurse (RN) is the most appropriate staff member to care for the client awaiting transfer from PACU following thoracic surgery. RNs have the education, training, and scope of practice to assess, monitor, and provide specialized care for post-surgical patients. They can recognize and manage potential complications, administer medications, and coordinate the client's care effectively. Assigning the charge nurse (
A) may compromise the overall management of the unit. LPNs (
C) have a more limited scope of practice and may not have the necessary skills for post-surgical care. Assistive personnel (
D) are not qualified to provide the level of care required for a client following thoracic surgery.

Correct Answer: A

Rationale: The correct answer is A. In the nursing process, the first step in addressing a client's unsatisfactory pain relief is to reassess the client to determine the reasons for it. This involves evaluating the pain intensity, location, characteristics, aggravating factors, and the client's response to current pain management interventions. By reassessing, the nurse can identify any underlying causes contributing to the lack of pain relief and adjust the plan of care accordingly.


Choice B is incorrect because waiting another 24 hours without further assessment delays appropriate intervention.
Choice C is incorrect as changing the plan without reassessment may not address the root cause of the issue.
Choice D is incorrect as teaching the client about the plan of care should come after reassessment to ensure it is tailored to the client's specific needs.

Correct Answer: A, D, E, F

Rationale: Objective data refers to measurable and observable information.
A: Respiratory rate and breathing pattern can be directly observed and counted, making it objective data.
D: Skin color, temperature, and moisture can be seen and felt, making it objective data.
E: Urine output is quantifiable and measurable, making it objective data.
F: The cleanliness, dryness, and integrity of a dressing can be visually assessed, making it objective data.
The other choices involve subjective experiences or interpretations (
B), self-reported pain level (
C), or may require additional assessments beyond direct observation (G).

Correct Answer: C, D, E

Rationale:
Correct
Answer: C, D, E


Rationale:
C: Showing a client how to use progressive muscle relaxation is an example of a nurse-initiated action as it involves client education and does not require a provider's prescription.
D: Performing a daily bath after the evening meal is a routine nursing care activity that can be initiated by the nurse without a provider's prescription.
E: Re-positioning a client every 2 hours to reduce the risk of pressure ulcers is an essential nursing intervention that can be initiated by the nurse without a provider's prescription.

Summary of Incorrect

Choices:
A: Giving morphine sulfate IV every 1 hour as needed for pain requires a provider's prescription due to the administration of a controlled substance.
B: Inserting an NG tube to relieve gastric distension is an invasive procedure that typically requires a provider's order and specialized training.

Correct Answer: A

Rationale: The correct answer is A because during evaluation, nurses must gather information about the client to identify whether client outcomes have been met. This step is crucial in determining the effectiveness of the care provided and if the client's needs have been addressed. Gathering this information helps in assessing the success of the interventions implemented.

Choice B is incorrect as organizing resources is part of the planning phase, not evaluation.
Choice C is incorrect because establishing client-centered outcomes is part of the planning phase, not evaluation.
Choice D is incorrect as determining priority of care and appropriate interventions is typically done during the assessment and planning phases, not evaluation.