ATI RN
Nursing Process Questions Questions
Question 1 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, impairing gas exchange. The nurse chose this diagnosis based on the patient's chest x-ray results indicating lower lobe infiltrates, which directly affect gas exchange. Choice A is incorrect because "ineffective breathing pattern" does not specifically address the underlying physiological issue of impaired gas exchange. Choice B is incorrect as it focuses on infection risk from the chest x-ray procedure, not the patient's medical condition. Choice C is incorrect as dehydration is not directly related to pneumonia and infiltrates.
Question 2 of 5
The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows: 1. The patient has a standing order for acetaminjson for headache relief. 2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours. 3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs. Summary: - Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order. - Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision. - Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.
Question 3 of 5
Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Dressing changes twice a day help maintain a clean wound environment, reducing the risk of infection. 2. Regular dressing changes promote proper wound healing by facilitating moisture balance and removal of dead tissue. 3. It is a direct intervention that addresses the patient's poor wound healing. 4. Teaching the patient about signs of infection (B) is important but does not directly address the wound healing process. 5. Instructing the family on dressing changes (C) is helpful but should not substitute direct patient care. 6. Refocusing the patient from body image changes (D) is not directly related to improving wound healing.
Question 4 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 5 of 5
A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data?
Correct Answer: B
Rationale: Subjective data refers to information provided by the client based on their feelings, perceptions, or beliefs. Nausea is a symptom that the client experiences and reports subjectively. The client feels nauseous, which is not something directly measurable like blood pressure, heart rate, or respiratory rate. Therefore, nausea is the correct choice for subjective data. Blood pressure, heart rate, and respiratory rate are all objective data that can be measured and observed. Blood pressure, heart rate, and respiratory rate are all objective data that can be measured and observed.