ATI RN
Nursing Process Questions Questions
Question 1 of 5
Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
Correct Answer: A
Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals.
Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase.
Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.
Question 2 of 5
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
Correct Answer: C
Rationale: Objective data in nursing refers to measurable and observable information. Respirations at 16 per minute are a specific, quantifiable measurement that the nurse can directly observe, making it objective data. This information is vital for assessing the patient's respiratory status accurately.
Choice A is incorrect because stating "doesn't feel good" is a subjective statement based on the patient's perception and cannot be directly measured or observed.
Choice B, reporting a headache, is also subjective as it relies on the patient's description of their symptoms.
Choice D, being nauseated, is subjective as well, as it is a symptom reported by the patient and not a quantifiable measurement.
In summary, choice C is correct as it represents objective data due to its quantifiable and observable nature, while the other choices are subjective and based on the patient's perceptions or feelings.
Question 3 of 5
A client’s blood glucose levels remain elevated despite adherence to the prescribed treatment plan. What is the nurse’s best action?
Correct Answer: A
Rationale: The correct answer is A because reassessing the client's diet, medication, and lifestyle habits allows the nurse to identify any factors contributing to the elevated blood glucose levels. By identifying possible issues, the nurse can make necessary adjustments to the treatment plan to better manage the client's condition. Increasing medication dosage without understanding the root cause may lead to adverse effects. Simply documenting the elevated levels without taking proactive measures does not address the problem. Notifying the client's family is not the nurse's first action; the focus should be on assessing and addressing the client's needs.
Question 4 of 5
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
Correct Answer: C
Rationale: Objective data are measurable and observable facts obtained through physical examination or diagnostic tests. In this case, "Respirations 16" is a quantifiable and observable measurement, making it objective data. It is not influenced by personal interpretation or feelings. The other choices, such as "States 'doesn't feel good'", "Reports a headache", and "Nauseated" are subjective data because they are based on the patient's feelings or experiences, which can vary depending on individual perception and interpretation, making them less reliable for making clinical decisions. By focusing on objective data like "Respirations 16", the nurse can provide a more accurate assessment of the patient's condition.
Question 5 of 5
Which of the ff. nursing interventions will help prevent complications in the patient with Bell’s Palsy?
Correct Answer: D
Rationale:
Correct
Answer: D - Lubricating eye drops
Rationale: Lubricating eye drops help prevent complications such as corneal abrasions in patients with Bell's Palsy by keeping the eye moist and preventing dryness. Bell's Palsy can cause difficulty in closing the eye properly, leading to dryness and potential damage to the cornea. Using lubricating eye drops helps maintain eye health.
Summary of Incorrect
Choices:
A: Megavitamin therapy - Not directly related to preventing complications in Bell's Palsy.
B: Application of ice to the affected area - Ice may not address eye dryness or prevent corneal abrasions.
C: Elastic bandages - Not relevant to preventing complications associated with Bell's Palsy.