ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 9
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
Correct Answer: C
Rationale: The correct answer is C. The nurse should ask the NAP to record the patient's vital signs before administering medications. This is important for ensuring patient safety and monitoring any potential changes in the patient's condition. By having the NAP record the vital signs, the nurse can assess the patient's current status and make informed decisions regarding medication administration. Option A is incorrect because administering medications without knowing the patient's vital signs, especially if they are abnormal, can be risky. Option B is not the best choice as it delays addressing the missing vital signs. Option D is incorrect as omitting vital signs assessment is not in line with best practices for patient care.
Question 2 of 9
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
Correct Answer: C
Rationale: Rationale: 1. Safety: Recording vital signs is crucial for patient safety. 2. Accountability: The nurse is ultimately responsible for ensuring vital signs are documented accurately. 3. Communication: It is essential for the nurse to communicate with the NAP to address the missed vital signs. 4. Corrective Action: Asking the NAP to record vital signs before administering medications ensures proper monitoring. 5. Patient-Centered Care: Prioritizing patient well-being by ensuring vital signs are up-to-date. Summary: A: Incorrect. Administering medications without vital sign assessment is unsafe. B: Incorrect. Reviewing vital signs upon return does not address the immediate need for accurate documentation. D: Incorrect. Omitting vital signs compromises patient safety and violates standard nursing practice.
Question 3 of 9
What are the nursing interventions for a client with thalassemia?
Correct Answer: A
Rationale: The correct answer is A because thalassemia is a genetic blood disorder that can cause anemia and fatigue. By maintaining the client on bed rest and protecting them from infections, we can help prevent complications such as fatigue and infections due to reduced red blood cell production. Ambulating the client frequently (choice B) may lead to increased fatigue and risk of injury. Advising to drink 3 quarts of fluid per day (choice C) is not specific to thalassemia treatment and could potentially worsen symptoms. Instructing the client to elevate lower extremities (choice D) is not directly related to managing thalassemia and may not provide significant benefits in this context.
Question 4 of 9
The ff are the tonometer measurements of five clients. Which of them has normal intraocular pressure (IOP)? Choose all that apply
Correct Answer: C
Rationale: The normal range for intraocular pressure (IOP) is approximately 10-21 mm Hg. Choice C has an IOP of 11 mm Hg, falling within this normal range, making it the correct answer. Choices A, B, and D are outside the normal range, with A being too low and B and D being too high, indicating abnormal IOP levels. Choice A (8 mm Hg) is below the normal range, while choices B (25 mm Hg) and D (28 mm Hg) are above the normal range, therefore, they are incorrect answers.
Question 5 of 9
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
Correct Answer: D
Rationale: The correct answer is D: “Remain supine for the time specified by the physician.” After a subarachnoid block, the client must remain lying down to prevent complications like spinal headaches due to cerebrospinal fluid leakage. This position helps maintain adequate spinal fluid pressure. Choice A is incorrect as fluid intake is important postoperatively. Choice B is not relevant to a subarachnoid block. Choice C is important but not the most crucial instruction compared to maintaining the supine position.
Question 6 of 9
A patient’s chest x-ray examination indicates fluid in both lung bases. Which of the ff. signs or symptoms present during the nurse’s assessment most reflects these x-ray examination findings?
Correct Answer: C
Rationale: The correct answer is C, bilateral crackles. Fluid in both lung bases on x-ray indicates pulmonary edema, causing crackles on auscultation. Fatigue (A) is a nonspecific symptom. Peripheral edema (B) is a sign of fluid retention in the extremities, not lungs. Jugular vein distention (D) indicates increased central venous pressure, which is not specific to lung fluid.
Question 7 of 9
What is an example of a nurse modifying the care plan during the evaluation phase?
Correct Answer: A
Rationale: The correct answer is A because modifying the care plan during the evaluation phase involves making changes based on the client's response to interventions. By adding a new intervention to address an unmet goal, the nurse demonstrates critical thinking and adaptability in response to the client's needs. This action shows that the nurse is actively assessing and revising the care plan to ensure it is effective in meeting the client's goals. Choice B is incorrect because routine monitoring is part of the assessment and implementation phases, not specifically related to modifying the care plan during evaluation. Choice C is incorrect as administering medication is part of the implementation phase and does not necessarily involve modifying the care plan. Choice D is also incorrect as completing discharge paperwork is typically part of the discharge planning phase, not the evaluation phase where modifications to the care plan are made based on client outcomes.
Question 8 of 9
Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
Correct Answer: C
Rationale: The correct answer is C: Position lower extremities below level of heart. This intervention helps improve blood flow and perfusion to the lower extremities by utilizing gravity to assist in venous return. This is crucial for clients at risk for ineffective tissue perfusion post-cardiac surgery. A: Restricting fluid intake may lead to dehydration, which can worsen tissue perfusion. B: Ensuring the client avoids prolonged sitting is important for preventing blood clots, but it does not directly address tissue perfusion. D: Instructing the client to avoid leg exercises may hinder circulation and exacerbate issues related to tissue perfusion.
Question 9 of 9
Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
Correct Answer: B
Rationale: The correct answer is B: Acute pain. This is the only choice that aligns with NANDA-I approved nursing diagnoses. Acute pain is a common nursing diagnosis that focuses on addressing a patient's immediate discomfort. NANDA-I emphasizes the importance of using standardized nursing diagnoses to improve communication and ensure proper interventions. Sore throat (A) and sleep apnea (C) are symptoms or medical diagnoses, not specific nursing diagnoses. Heart failure (D) is a medical diagnosis and not a NANDA-I approved nursing diagnosis.