ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
Mr. Reyes has a possible skull fracture. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because observing for signs of brain injury is crucial in assessing a possible skull fracture. Signs may include altered mental status, headache, nausea, vomiting, and unequal pupil size. Choice B is incorrect as hemorrhaging from the oral cavity may not always be present in skull fractures. Choice C is incorrect as elevating the foot of the bed is not recommended for a possible skull fracture. Choice D is incorrect as decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
Question 2 of 5
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A because completing a comprehensive database is part of the first phase of the nursing process, which is assessment. During assessment, the nurse gathers data about the patient's health status. This information is crucial for identifying health problems, developing nursing diagnoses, planning interventions, and evaluating outcomes. Choice B is incorrect because identifying nursing diagnoses is part of the second phase, which is diagnosis. Choice C is incorrect as intervening based on priorities of patient care is part of the third phase, which is planning. Choice D is incorrect because determining whether outcomes have been achieved is part of the fourth phase, which is evaluation.
Question 3 of 5
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. During the first phase of the nursing process (assessment), the nurse collects data to establish a comprehensive database of the patient's health status. This information serves as the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities (C) in the third phase (planning), and determining outcomes achieved (D) in the fourth phase (evaluation). Completing a comprehensive database is crucial in the initial assessment phase to gather accurate information for the subsequent steps in the nursing process.
Question 4 of 5
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A because during the first phase of the nursing process (assessment), the nurse collects a comprehensive database of information about the patient's health status and needs. This data forms the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Choices B, C, and D involve actions that occur in the subsequent phases of the nursing process (diagnosis, planning, and evaluation), not in the initial assessment phase. Therefore, A is the correct choice for the first phase.
Question 5 of 5
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A because during the first phase of the nursing process (assessment), the nurse gathers a comprehensive database of information about the patient's health status. This includes collecting subjective and objective data to form a baseline for further decision-making. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining outcomes (D) is done in the final phase (evaluation). Therefore, completing a comprehensive database is the most appropriate action in the first phase.