ATI RN
Nursing Process Practice Questions Questions
Question 1 of 9
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B - Focus on the patient's presenting situation. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan. Now, let's analyze the other choices: A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific and relevant data.
Question 2 of 9
In the operating room, personnel should be responsible for ensuring cleanliness, proper temperature, humidity, and lighting. Who carries those responsibilities?
Correct Answer: A
Rationale: The correct answer is A: circulating nurse. The circulating nurse is responsible for maintaining cleanliness, ensuring proper temperature, humidity, and lighting in the operating room. They coordinate activities, manage supplies, and ensure a safe environment for the surgical team. The scrub nurse assists the surgeon with instruments and supplies, not environmental conditions. The surgeon's main focus is on performing the surgery, not environmental management. The anesthesiologist is responsible for administering anesthesia and monitoring the patient's vital signs, not the operating room environment.
Question 3 of 9
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient’s presenting situation. In the problem-oriented approach, the nurse prioritizes the patient's immediate concerns to address them effectively. By focusing on the presenting situation first, the nurse can gather relevant data and identify key issues. This step ensures that the nurse addresses the most pressing problems promptly. A: Completing questions in chronological order may not be necessary and could delay addressing the immediate concern. C: Making accurate interpretations of data should come after gathering relevant information about the presenting situation. D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific data.
Question 4 of 9
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
Correct Answer: D
Rationale: The correct answer is D because developing a formal nursing diagnosis helps nurses focus on their scope of practice, which includes identifying and addressing the patient's nursing care needs. By formulating a clear nursing diagnosis, nurses can prioritize interventions that are within their domain of expertise. This ensures efficient and effective patient care delivery. A: Incorrect. Developing a nursing diagnosis is not about creating a language exclusive to nurses; it is about identifying patient care needs. B: Incorrect. While nursing diagnoses do delineate the nurse's role, the primary purpose is not to distinguish it from the physician's role. C: Incorrect. Nursing diagnoses are based on evidence and critical thinking, not solely on intuition or others' judgments.
Question 5 of 9
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
Correct Answer: D
Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on their scope of practice, which involves identifying and addressing the patient's nursing care needs. By formulating a specific nursing diagnosis, nurses can prioritize interventions and provide individualized care. Choice A is incorrect as nursing diagnoses are not exclusive to nurses. Choice B is incorrect because nursing and physician roles overlap. Choice C is incorrect as clinical judgment should be based on evidence and critical thinking, not solely on intuition.
Question 6 of 9
A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery-this will go away on its own”. In considering her response to the client, the nurse must depend on the ethical principle of:
Correct Answer: C
Rationale: The correct answer is C: Autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their own healthcare. In this scenario, the client is expressing her desire to not undergo surgery, which is her right as an autonomous individual. The nurse must respect her decision even if it goes against medical advice. Beneficence (A) is the ethical principle of doing good for the patient, but in this case, respecting the client's autonomy takes precedence. Advocacy (B) involves supporting the client's best interests, which could align with autonomy in this case. Justice (D) refers to fairness and equal treatment, but it is not directly applicable to the client's decision regarding surgery.
Question 7 of 9
Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
Correct Answer: D
Rationale: Rationale: - Choice D is correct as it offers the patient autonomy and promotes self-care, which is important for maintaining independence and dignity. - By giving the patient a choice between brushing their own teeth or having assistance, it empowers them to make decisions. - Choices A, B, and C are not as appropriate because they do not address the patient's autonomy and may come across as directive or intrusive, which can further exacerbate the altered thought process.
Question 8 of 9
Which of the following reflects the importance of client-centered care during the evaluation phase?
Correct Answer: B
Rationale: The correct answer is B because client-centered care emphasizes involving clients in decision-making. During evaluation, assessing if the care plan aligns with the client's preferences and goals ensures personalized and effective care. This approach enhances client satisfaction, engagement, and outcomes. Incorrect choices: A: Not considering the client's input goes against client-centered care principles. C: Prioritizing institutional policies over client feedback neglects the client's individual needs. D: Focusing solely on measurable clinical outcomes may not capture the holistic view of the client's well-being.
Question 9 of 9
A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, 'I am very nervous and scared to have surgery.' What client outcome is the priority?
Correct Answer: B
Rationale: The correct answer is B: Resolve the client’s anxiety. Addressing the client's anxiety is the priority because it can impact their overall surgical experience, recovery, and outcomes. Resolving anxiety can improve the client's emotional well-being, enhance cooperation during surgery, and reduce postoperative complications related to stress. Providing emotional support and reassurance should be the initial focus to help the client feel more comfortable and confident about the upcoming surgery. The other choices are not the priority in this situation: A) Evaluating the need for antibiotics can be addressed later in the preoperative process, C) Providing preoperative education is important but not the immediate priority over addressing anxiety, and D) Preparing the client for surgery includes various components, but emotional well-being should be addressed first.