Questions 9

ATI RN

ATI RN Test Bank

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 because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is based on the patient's subjective feelings and concerns, which are important to address for a safe discharge. Choices A and B are incorrect as they assume the patient's readiness for independent tasks without considering their emotional state. Choice D is incorrect as there is no objective data provided to support the assumption that the surgery was not successful. It is important for the nurse to acknowledge and address the patient's emotional needs before discharge.

Question 2 of 5

A client is admitted to the hospital with a bleeding ulcer and is to receive 4 units of packed cells. Which nursing intervention is of primary importance in the administration of blood?

Correct Answer: C

Rationale: Step 1: Identifying the client is crucial for correct blood transfusion to avoid errors. Step 2: Client identification includes verifying name, date of birth, and unique identifiers. Step 3: Ensuring correct patient prevents transfusion reactions and improves patient safety. Step 4: Monitoring vital signs and flow rate are important but secondary to client identification. Step 5: Maintaining blood temperature is not a primary concern during blood transfusion.

Question 3 of 5

The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise this part of the diagnostic statement because impaired physical mobility related to tibial fracture is a nursing diagnosis, not a collaborative problem. Collaborative problems are issues that require both medical and nursing interventions, whereas nursing diagnoses are within the scope of nursing practice. The etiology identifies the cause of the problem (tibial fracture), the nursing diagnosis states the problem (impaired physical mobility), and the defining characteristic is the evidence that supports the diagnosis (inability to ambulate). Therefore, the nurse should revise the part stating collaborative problem as it does not align with the nature of the issue presented in the scenario.

Question 4 of 5

The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:

Correct Answer: A

Rationale: The correct answer is A: Below 70mg/dl. Hypoglycemia is defined as a blood glucose level below 70mg/dl. Symptoms of hypoglycemia include confusion, shakiness, and sweating. Treating hypoglycemia involves administering fast-acting carbohydrates. Choices B, C, and D are incorrect because they describe blood glucose levels that are within the normal or hyperglycemic range, which are not indicative of hypoglycemia. It is essential for the nurse to recognize and promptly address hypoglycemia to prevent serious complications.

Question 5 of 5

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?

Correct Answer: B

Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a cerebellar brain tumor can affect the client's coordination and balance due to its location in the brain responsible for fine motor movements. Impaired balance increases the risk for falls and injuries. Visual field deficits (choice A) may contribute to the risk of injury but not as directly as impaired balance. Difficulty swallowing (choice C) and psychomotor seizures (choice D) are not directly related to the client's risk for injury due to a cerebellar brain tumor.

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