ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for this patient is acute pain (Choice C). This is because the patient's right femur fracture would likely cause significant pain and discomfort, which is a priority to address for optimal recovery and comfort. Managing pain effectively is crucial in promoting healing and preventing complications. Posttrauma syndrome (Choice A) is not as immediate a concern in this scenario. While constipation (Choice B) and anxiety (Choice D) are important considerations, addressing acute pain takes precedence in the initial plan of care to ensure the patient's comfort and well-being.
Question 2 of 5
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
Correct Answer: D
Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery. Explanation for other choices: A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed. B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain. C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.
Question 3 of 5
A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?
Correct Answer: C
Rationale: The correct answer is C: “Nurses use evaluation to determine the effectiveness of nursing care.” Evaluation in nursing is essential to assess the outcomes of nursing interventions and determine the effectiveness of the care provided. It helps in identifying areas for improvement, making informed decisions, and ensuring quality patient care. Choice A is incorrect because evaluation is not solely about checking completion of tasks but rather assessing the impact of those interventions on patient outcomes. Choice B is incorrect as evaluation is not related to staffing decisions but focuses on assessing the quality of care delivery. Choice D is incorrect as evaluation is not about eliminating paperwork but rather about improving care outcomes.
Question 4 of 5
A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation?
Correct Answer: A
Rationale: The correct answer is A because it encourages the novice nurse to independently observe the situation with a peer, validate the data, and discuss afterward. This approach promotes reflection, peer learning, and validation of collected data, which are essential for learning and growth. It allows the nurse to self-assess and correct errors through discussion and feedback. Choice B is incorrect as it does not address the need for validation and peer feedback. Choice C is incorrect as repeating the same mistake without guidance does not promote learning. Choice D is incorrect as meeting with the nurse manager may not provide the same level of peer learning and validation as observing with a peer.
Question 5 of 5
A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client’s vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment?
Correct Answer: B
Rationale: The correct answer is B: Focused assessment. In this scenario, the nurse is continuously monitoring specific aspects such as vital signs, pupils, and orientation at regular intervals, which is characteristic of a focused assessment. This type of assessment allows the nurse to gather specific data related to the client's condition and respond promptly to any changes. A: Initial assessment is conducted upon admission to establish baseline data. C: Time-lapsed reassessment involves comparing current data to previous assessments over a longer period. D: Emergency assessment is performed in urgent situations to quickly identify life-threatening issues. By systematically assessing the client's vital signs, pupils, and orientation at frequent intervals, the nurse can provide timely and appropriate care in the intensive care unit setting.