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
What does a nurse assess postoperatively in a client with a nasal fracture?
Correct Answer: C
Rationale: The correct answer is C: Airway obstruction. Postoperatively, a nurse must assess for airway patency in a client with a nasal fracture to ensure proper breathing. Any swelling or bleeding in the nasal area can lead to airway obstruction, which is a critical concern that needs immediate intervention. Choices A, B, and D are incorrect because an allergic reaction, extreme sense of smell, and stridor are not typically associated with postoperative assessment of a nasal fracture. It is crucial to prioritize airway assessment to prevent any complications related to breathing difficulties in this situation.
Question 3 of 9
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.
Question 4 of 9
The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
Correct Answer: C
Rationale: The correct next step after identifying nursing diagnoses is planning. Planning involves setting goals and creating a plan of care to address the patient's needs based on the identified nursing diagnoses. This step helps in determining interventions and outcomes for the patient. Assessment has already been completed, and diagnosis is the step where nursing diagnoses are identified. Implementation comes after planning, where the nurse carries out the planned interventions. Therefore, the logical next step in the nursing process after identifying nursing diagnoses is planning.
Question 5 of 9
A patient has iron deficiency anemia. Which of the following foods will best help provide dietary iron?
Correct Answer: C
Rationale: The correct answer is C: Lean red meats. Lean red meats are a rich source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Heme iron helps improve iron levels more effectively in individuals with iron deficiency anemia. Fresh fruits (A) and dairy products (B) contain minimal iron, while breads and cereals (D) provide non-heme iron which is not as readily absorbed.
Question 6 of 9
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.
Question 7 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 8 of 9
A client becomes upset when the physician diagnoses diabetes mellitus as the cause of current signs and symptoms. The client tells the nurse, “This must be a mistake. No one in my family has ever had diabetes.” Based on this statement, the nurse suspects the client is using which coping mechanism?
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's refusal to accept the diagnosis of diabetes mellitus, stating that no one in their family has had it, indicates denial as a coping mechanism. Denial is a defense mechanism where individuals refuse to acknowledge unpleasant realities. In this case, the client is rejecting the diagnosis to avoid facing the reality of having a chronic condition. The other choices (B: Anger, C: Withdrawal, D: Resolution) do not fit the client's response in this scenario. Anger involves expressing frustration or hostility, withdrawal is avoiding the situation, and resolution is accepting and dealing with the issue.
Question 9 of 9
A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. The ff. nursing interventions might be recommended to help prevent aspiration during eating except:
Correct Answer: A
Rationale: The correct answer is A because providing clear liquids only until the patient can swallow solid foods is not a recommended nursing intervention to prevent aspiration. Clear liquids do not require the same level of swallowing coordination as solid foods, so it may not help improve swallowing ability. B: Having the patient swallow twice after each bite can help clear the throat and reduce the risk of aspiration. C: Placing food on the unaffected side of the mouth can help direct the food towards the stronger side for swallowing. D: Checking the patient's mouth for pocketing of food is important to ensure that food is not being retained in the mouth, which could lead to aspiration.