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: 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 2 of 9
The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?
Correct Answer: D
Rationale: Step 1: Define nonmodifiable risk factors - these are factors that cannot be changed or controlled by the individual. Step 2: Advanced age is a nonmodifiable risk factor as it is determined by genetics and time. Step 3: Poor control of blood glucose levels, foot trauma, and inappropriate foot care are modifiable risk factors that can be managed through lifestyle changes or medical interventions. Summary: Choice D is correct because advanced age is a nonmodifiable risk factor for diabetes mellitus, while the other choices involve factors that can be modified through appropriate actions.
Question 3 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 4 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 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 9
Nursing assessment for a patient with metabolic alkalosis includes evaluation of laboratory data for all of the following except:
Correct Answer: C
Rationale: The correct answer is C: Hypoglycemia. In metabolic alkalosis, the blood pH is elevated due to an excess of bicarbonate. Hypoglycemia is not directly related to metabolic alkalosis but can be seen in other conditions like diabetes or fasting. Evaluating for hypocalcemia (A) is important as alkalosis can lead to decreased ionized calcium levels. Hypokalemia (B) is common in metabolic alkalosis due to potassium loss. Hypoxemia (D) is not directly related to metabolic alkalosis but can occur in severe cases due to respiratory compensation. Therefore, hypoglycemia is the least relevant in assessing metabolic alkalosis.
Question 6 of 9
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
Correct Answer: A
Rationale: The correct answer is A: Cancerous lumps. Breast self-examination aims to detect any abnormal changes in the breasts, including potential cancerous lumps. Detecting cancerous lumps early increases the chances of successful treatment and improved outcomes. Choices B, C, and D are incorrect because while changes from previous self-examinations, areas of thickness or fullness, and fibrocystic masses can be important to note, the primary goal of breast self-examination is to identify any signs of breast cancer, such as cancerous lumps.
Question 7 of 9
The most effective pharmacologic agent for the treatment of Parkinson’s disease is:
Correct Answer: A
Rationale: The correct answer is A: Levodopa. Levodopa is the most effective pharmacologic agent for treating Parkinson's disease because it is converted to dopamine in the brain, replenishing the deficient dopamine levels in Parkinson's patients. Selegiline and Symmetrel are also used in treating Parkinson's, but they are typically used as adjunctive therapy rather than the primary treatment. Permax has been withdrawn from the market due to safety concerns, making it an incorrect choice.
Question 8 of 9
The following are warning signs of cancer. Which one is not?
Correct Answer: B
Rationale: The correct answer is B, weight gain, as it is not typically considered a warning sign of cancer. Changes in bladder and bowel habits (A), indigestion or difficulty in swallowing (C), and a nagging cough or hoarseness (D) are commonly associated with various types of cancer. Weight gain is more commonly linked to factors such as diet, exercise, and hormonal imbalances rather than cancer. It is important to be vigilant about the other warning signs and seek medical attention if any of those symptoms persist.
Question 9 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.