ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
Correct Answer: C
Rationale: The correct answer is C: The patient is apprehensive about discharge. The rationale is that the patient's fear of going home and being alone indicates anxiety about leaving the hospital setting. This subjective data suggests that the patient may not feel ready for discharge despite stable vital signs and nearly healed incision. Choices A and B are incorrect because they assume the patient's readiness for self-care without considering emotional factors. Choice D is incorrect as there is no evidence provided that the surgery was unsuccessful.
Question 2 of 5
When caring for a patient with AIDS, which of the following nursing actions would be the most appropriate for infection control?
Correct Answer: C
Rationale: The correct answer is C: Wear gloves for blood/body fluid contact. This is the most appropriate action for infection control when caring for a patient with AIDS because HIV is primarily transmitted through blood and certain body fluids. Wearing gloves when coming into contact with blood or body fluids reduces the risk of transmission. Explanation for why other choices are incorrect: A: Wearing gloves at all times may not be necessary and can lead to unnecessary waste of resources. B: Wearing gown and mask at all times is excessive and not indicated unless there is a risk of exposure to blood or body fluids. D: Wearing a mask during patient contact times is not necessary unless there is a risk of exposure to respiratory secretions.
Question 3 of 5
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
Correct Answer: C
Rationale: The correct answer is C: The patient is apprehensive about discharge. The rationale is that the patient's fear of going home and being alone indicates anxiety about leaving the hospital setting. This subjective data suggests that the patient may not feel ready for discharge despite stable vital signs and nearly healed incision. Choices A and B are incorrect because they assume the patient's readiness for self-care without considering emotional factors. Choice D is incorrect as there is no evidence provided that the surgery was unsuccessful.
Question 4 of 5
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient’s plan of care?
Correct Answer: C
Rationale: The correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance. A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit. B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake. D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.
Question 5 of 5
Arthur, a 66-year old client for pneumonia has a temperature ranging from 39° to 40° C with periods of diaphoresis. Which of the following interventions by Nurse Carlos would be a priority?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.
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