ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 5
An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first?
Correct Answer: A
Rationale: The correct answer is A: The client’s airway should be assessed first. This is because airway management is the top priority in any emergency situation to ensure the patient can breathe. Without a patent airway, the patient's oxygenation and ventilation will be compromised, leading to serious complications or death. Choices B, C, and D are incorrect because assessing the airway takes precedence over determining the reason for admission, reviewing medications, or assessing past medical history in an unconscious patient. These other assessments are important but not as critical as securing the airway to maintain the patient's breathing and oxygenation.
Question 2 of 5
A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority?
Correct Answer: B
Rationale: The correct answer is B: The need to feel good about oneself. This is the priority because the resident's refusal to eat is tied to her desire to maintain her personal appearance and feel good about herself. By addressing this need first, the resident may become more willing to eat. The other choices are incorrect because while nutrition (A) is important, addressing the resident's self-esteem and well-being should come first. The need to live in a safe environment (C) is also important but not the priority in this specific scenario. The need for love from others (D) is significant but not directly related to the resident's refusal to eat based on her personal grooming preferences.
Question 3 of 5
What is the primary purpose of the implementation step in the nursing process?
Correct Answer: B
Rationale: The correct answer is B: To carry out the plan of care. In the nursing process, implementation is the phase where nurses put the established care plan into action by delivering the interventions outlined to meet the client's needs. This step is crucial as it ensures that the care plan is executed effectively and efficiently. Establishing priorities (A) is done during the planning phase, identifying client outcomes (C) is part of the evaluation phase, and validating nursing diagnoses (D) is typically done during the assessment phase, not implementation.
Question 4 of 5
A female client age 66 is admitted ff a nephrolithomy. One of her laboratory tests reveals a urinary tract infection. Which would be the best nursing action in her case?
Correct Answer: C
Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation. Incorrect Choices: A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection. B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection. D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.
Question 5 of 5
Which of the ff is the most important factor in the nursing management of clients who undergo treatment for a malignant tumor ff the urinary diversion procedure?
Correct Answer: C
Rationale: The correct answer is C: Observing for leakage of urine or stool from the anastomosis. This is crucial in nursing management post-urinary diversion procedure to prevent complications such as infection, dehydration, and skin breakdown. Leakage can indicate issues with the surgical site integrity and requires prompt intervention. A: Placement of IV and central venous pressure lines is important but not as critical as monitoring for leakage from the anastomosis. B: Administering cleansing enemas may be necessary for certain procedures but is not the most important factor in this case. D: Assessing the client's ability to manage self-catheterization is important for long-term care but does not take precedence over monitoring for potential complications like leakage. In summary, option C is the most important factor as it directly impacts the client's immediate post-operative care and helps prevent serious complications.