ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?
Correct Answer: C
Rationale: The correct answer is C: Disruption of tissue integrity. Acute pain is typically caused by tissue damage or injury, such as a cut or a burn. The nurse would use this assessment data as an etiology for acute pain because it directly relates to the source of the pain. Discomfort while changing position (A) is a symptom of pain but does not provide the underlying cause. Reports pain as a 7 on a 0 to 10 scale (B) is a pain intensity rating and does not explain the cause of the pain. Dull headache (D) is a specific type of pain but is not relevant to the given scenario of tissue disruption.
Question 2 of 5
What is the nurse’s firstaction?
Correct Answer: B
Rationale: The correct answer is B. First, reviewing lab results for potassium level is important in assessing potential electrolyte imbalances that may contribute to the patient's symptoms. This allows for a comprehensive understanding of the patient's condition. Assessing the patient for other symptoms or problems is crucial to gather additional information. Finally, notifying the healthcare provider ensures timely communication and collaboration for appropriate care. Choice A is incorrect as following a clinical protocol for a stroke is premature without a comprehensive assessment. Choice C is incorrect as administering medication without a thorough assessment and provider notification can be dangerous. Choice D is incorrect as notifying the healthcare provider should precede administering any medication.
Question 3 of 5
A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? “Evaluative measures are multiple-page documents used to evaluate nurse
Correct Answer: B
Rationale: The correct answer is B because evaluative measures in nursing refer to the assessment data used to determine if patients have achieved their expected outcomes and goals. This is crucial in evaluating the effectiveness of the care provided. Choice A is incorrect because it defines evaluative measures as multiple-page documents, which is not accurate. Choice C is incorrect as it focuses on the progression of a nurse's skill level rather than patient outcomes. Choice D is incorrect as it defines evaluative measures as objective views of completing nursing interventions, which is too narrow of a definition.
Question 4 of 5
A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
Correct Answer: C
Rationale: The correct answer is C: Time-lapsed assessment. This type of assessment involves comparing baseline data with new data collected at a later time to evaluate changes in the client's condition. In this scenario, the nurse is reassessing the client a month later to determine if there have been any changes that require adjustments to the care plan. A: Comprehensive assessment is an in-depth assessment done initially to gather detailed information about the client's overall health status. B: Focused assessment is done to gather specific information related to a particular problem or issue. D: Emergency assessment is performed in urgent situations to quickly identify and address life-threatening conditions.
Question 5 of 5
Which of the following data regarding a client with a diagnosis of colon cancer are subjective?
Correct Answer: A
Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception. Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.