ATI RN
Nursing Process Questions Questions
Question 1 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, such as vital signs. Respirations of 16 are a specific numerical measurement that can be quantified. This makes choice C the correct answer as it is factual and quantifiable.
Choices A, B, and D are subjective data, as they rely on the patient's feelings or experiences, which are open to interpretation and not measurable.
Therefore, the nurse should report choice C as objective data as it provides concrete information for assessment and decision-making.
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 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 3 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. Respirations (
C) of 16 per minute is objective data as it is a quantifiable measurement that can be counted and recorded. It is not influenced by personal interpretation or bias.
Choices A, B, and D are subjective data as they rely on the patient's feelings, perceptions, or symptoms, which can vary and are open to interpretation.
Therefore, choice C is the correct answer as it represents concrete, verifiable information that can be used in the patient's assessment and care planning.
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: The correct answer is C because respirations of 16 is an observable and measurable data point that can be quantified. Objective data are factual, measurable, and based on observable phenomena. In contrast, choices A, B, and D are subjective data as they rely on the patient's feelings or experiences, which are not directly measurable or observable by the nurse. Reporting a headache or feeling nauseated are subjective symptoms that are based on the patient's perception and cannot be verified without further assessment.
Therefore, only choice C provides objective data that can be accurately reported by the nurse.
Question 5 of 5
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue.
A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty.
B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition.
C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem.
In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.