ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 5
A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Evaluation. After implementing nursing interventions based on priority diagnoses, the nurse must evaluate the effectiveness of these interventions to determine if the desired outcomes have been achieved. Evaluation is crucial to assess the progress, make necessary modifications, and ensure the effectiveness of the care provided. Assessment (A) is already completed before interventions are carried out. Planning (B) involves developing a care plan based on assessment findings. Implementation (C) is the actual carrying out of the interventions. Therefore, the next step after implementing nursing interventions is to evaluate their effectiveness.
Question 2 of 5
The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client’s health status. Which of the following would the nurse identify as a subjective cue?
Correct Answer: A
Rationale: The correct answer is A because sharp pain is a subjective cue as it is based on the client's personal experience and perception. The client is the only one who can report the presence and intensity of pain. B: Small bloody drainage is an objective cue that can be observed and measured by the nurse. C: Temperature of 102 degrees F is an objective cue that can be measured using a thermometer. D: Pulse rate of 90 beats per minute is an objective cue that can be measured using a pulse oximeter. In summary, subjective cues are based on the client's feelings and perceptions, while objective cues are observable and measurable by the healthcare provider.
Question 3 of 5
A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease: 'Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language.' Which part of this diagnosis is considered the problem statement?
Correct Answer: A
Rationale: The correct answer is A: "Disturbed thought processes." This is the problem statement because it identifies the client's main issue, which is the disturbance in their thought processes. The "related to" part (B) indicates the cause, "Alzheimer's disease" (C) is the etiology, and "incoherent language" (D) is the evidence. By focusing on the problem statement, the nurse can develop appropriate interventions to address the client's disturbed thought processes.
Question 4 of 5
Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning?
Correct Answer: B
Rationale: The correct answer is B because during outcome identification and planning, it is crucial to prioritize problems that require immediate attention to ensure patient safety and well-being. By asking what problems need immediate attention, nurses can focus on addressing urgent issues first. Choice A focuses on data clustering for problem identification, choice C is related to defining characteristics for nursing diagnoses, and choice D pertains to documentation, which are important but not directly related to prioritizing immediate problems.
Question 5 of 5
What is the nurse’s primary legal responsibility when implementing nursing interventions?
Correct Answer: A
Rationale: The correct answer is A: Ensure client safety. This is the nurse's primary legal responsibility as it aligns with the ethical principle of beneficence, prioritizing the well-being and safety of the client. Ensuring client safety is essential to prevent harm and promote positive health outcomes. Following physician orders precisely (B) is important but not the primary legal responsibility of the nurse. Documenting care comprehensively (C) is crucial for accountability and continuity of care but is not the primary legal responsibility. Providing client-centered education (D) is essential for empowering clients but is not the primary legal responsibility in terms of legal accountability and duty of care.