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: Rationale for Correct Answer (C): Asking the NAP to record the patient's vital signs before administering medications is the correct clinical decision. Vital signs are crucial indicators of a patient's health status and should be documented before any interventions. By having the NAP record the vital signs, the nurse ensures that the patient's condition is properly assessed and monitored. This action aligns with the standard of care and promotes patient safety. Summary of Incorrect Choices: A: Administering medications without knowing the patient's vital signs could be dangerous, especially if there are abnormalities that need attention. B: Reviewing vital signs upon return delays necessary assessment and intervention, potentially compromising patient safety. D: Omitting vital signs without assessment puts the patient at risk, as changes in vital signs can indicate underlying issues that need immediate attention.
Question 2 of 5
A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?
Correct Answer: D
Rationale: The correct initial action to take after the patient falls is to assess the patient (Choice D). This is important to determine the extent of any injuries sustained, assess the patient's current condition, and identify any factors that may have contributed to the fall. By conducting a thorough assessment, the nurse can gather crucial information to inform the revision of the care plan. Consulting physical therapy (Choice A) may be necessary later on but is not the immediate priority. Establishing a new plan of care (Choice B) and setting new priorities (Choice C) should be based on the assessment findings, making Choice D the most appropriate initial action.
Question 3 of 5
The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A because protocols are indeed guidelines that assist clinicians in decision-making and choosing interventions for specific health care problems. This definition accurately reflects the purpose and function of protocols in nursing practice. Option B is incorrect as it describes protocols as policies related to nurses' duties and standards of care, which is more aligned with job descriptions and policies rather than protocols. Option C is incorrect as it relates protocols to a code of ethics, which is a separate concept that guides ethical decision-making and behavior in nursing practice. Option D is incorrect as it inaccurately describes protocols as prescriptive order forms, which are actually separate from protocols and are used for medication administration and treatment orders.
Question 4 of 5
A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Equipment. The nurse needs to ensure that necessary equipment is available to carry out interventions effectively and safely. Without the right equipment, the nurse may not be able to provide appropriate care. Safe environment (B) is important but not a resource that the nurse makes sure is available. Confidence (C) is a personal attribute and not a resource. Assistive personnel (D) are individuals who can help but are not resources that the nurse ensures are available.
Question 5 of 5
A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient’s responses to nursing care? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Observations of wound healing. This is the correct evaluative measure because it directly assesses the patient's response to nursing care, indicating the effectiveness of interventions. Wound healing is a tangible and visible indicator of the patient's overall health status and the success of nursing interventions. The other choices are incorrect: B: Daily blood pressure measurements do not solely indicate a patient's response to nursing care. Blood pressure can be affected by various factors unrelated to nursing interventions. C: Findings of respiratory rate and depth are important for assessing respiratory status but may not directly reflect the patient's response to nursing care. D: Completion of nursing interventions is a process measure and does not provide direct insight into the patient's response to care.