ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 3 : The Nursing Process Questions
Question 1 of 5
The RN is obtaining a health history and performing a physical assessment for a client who is admitted to the hospital with complaints of chest pain. What part of the nursing process is the RN performing?
Correct Answer: D
Rationale: Assessment is the careful observation and evaluation of a client's health status. The nurse collects information to determine abnormal function and risk factors that contribute to health problems as well as client strengths. Planning is establishing the outcomes and actions that will help achieve the overall goals. Implementation is putting the plan into action. Evaluation is determining the client's responses to the care provided.
Question 2 of 5
The RN develops an outcome standard of 'client will ambulate with an assistive device 60 feet with assistance twice a day' for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?
Correct Answer: B
Rationale: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
Question 3 of 5
A client has been admitted to the hospital with a large sacral pressure ulcer. The physician prescribes the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?
Correct Answer: D
Rationale: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal and prevent another formation of a wound. Recording the description of the wound would occur during the assessment phase of the nursing process. The prediction of how much and how soon the client's wound will heal would be made during the planning phase, while noting the amount the wound has healed on a given day is an example of a statement that would be made during the evaluation phase.
Question 4 of 5
The LPN plays a vital role in the development of a nursing diagnosis for a client. What role does the LPN have?
Correct Answer: A
Rationale: As in other phases of the nursing process, the nurse's role depends on their level of practice. LPN/LVNs report information that suggests actual or potential health problems. RNs examine and analyze the client database to formulate a nursing diagnosis.. The The physician is generally not involved in the nursing process and care planning of care for the client. The RN's role is to evaluate the effectiveness or resolving of the nursing diagnosis..
Question 5 of 5
The nurse is developing a care plan for a for a client who has had a stroke and is unable to assist with care at this time. Which Which problem would the nurse deem deem a top priority?
Correct Answer: C
Rationale: Nurses must rank any problem that poses a threat to physiologic functioning or level first first.. For example, a nursing diagnosis such as for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a breathing as a nursing intervention may life- life-threatening.. The second than life other is the second-level.. level and higher.. This relates to Maslow's hierarchy..