ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 5
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 5
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 5
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. The rationale is that NANDA-I (North American Nursing Diagnosis Association-International) approves nursing diagnoses that are specific, measurable, and relevant to nursing care. Acute pain fits these criteria as it is a common nursing diagnosis that can be assessed objectively and treated with nursing interventions. The other choices (sore throat, sleep apnea, heart failure) are medical diagnoses that do not fall under the scope of nursing diagnoses approved by NANDA-I. Therefore, acute pain is the most appropriate diagnosis to be documented in a patient's care plan according to NANDA-I guidelines.
Question 4 of 5
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 for Choice C: 1. Safety First: Recording vital signs is crucial for patient safety. Asking the NAP to record vital signs ensures the patient's condition is monitored before administering medications. 2. Accountability: Nurses are responsible for ensuring accurate documentation of vital signs. Asking the NAP to record them maintains accountability within the healthcare team. 3. Communication: By requesting the NAP to record vital signs, the nurse fosters effective communication and collaboration in patient care. Summary of Other Choices: A: Administering medications without reviewing vital signs could lead to adverse effects if there are abnormalities. B: Reviewing vital signs upon return delays immediate action and could jeopardize patient safety. D: Omitting vital signs neglects the essential monitoring required for patient care and could result in missed opportunities for early intervention.
Question 5 of 5
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. The NANDA-I (North American Nursing Diagnosis Association International) approved diagnosis must meet specific criteria related to patient assessment data, defining characteristics, and related factors. Acute pain is a well-defined nursing diagnosis with specific defining characteristics and related factors, making it a suitable and approved option for inclusion in a patient's care plan. Sore throat, sleep apnea, and heart failure do not meet the criteria for a NANDA-I approved diagnosis as they lack the specificity and comprehensive assessment data required for a nursing diagnosis.