ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise the collaborative problem part of the diagnostic statement because impaired physical mobility related to tibial fracture is a nursing diagnosis, not a collaborative problem. A collaborative problem involves potential complications that require both nursing and medical interventions. In this case, impaired physical mobility is a nursing diagnosis that requires nursing interventions to address the patient's inability to ambulate. Choices A, B, and D are incorrect because they are all relevant components of a nursing diagnostic statement: A - Etiology identifies the cause of the nursing diagnosis, B - Nursing diagnosis states the health problem, and D - Defining characteristic provides evidence supporting the nursing diagnosis.
Question 2 of 5
Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
Correct Answer: A
Rationale: The correct answer is A because determining whether an intervention is correct and appropriate for the given situation indicates critical thinking in nursing care implementation. This involves assessing the patient's needs, analyzing the situation, and using evidence-based practice to make informed decisions. This process ensures that interventions are tailored to individual patient needs and promotes safe and effective care delivery. Option B is incorrect because performing a procedure without clinical competency can jeopardize patient safety and is not an example of critical thinking. Option C is incorrect as establishing goals without assessment lacks a foundation in data and may lead to inappropriate care planning. Option D is incorrect as evaluating the effectiveness of interventions is a part of the nursing process but does not specifically demonstrate critical thinking in implementation.
Question 3 of 5
A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
Correct Answer: D
Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation involves determining if the patient's condition has improved and if the expected outcomes have been met. The nurse assesses the patient's progress, compares it to the expected outcomes set during planning, and determines the effectiveness of the interventions implemented. This step ensures that the care provided is meeting the patient's needs and helps in making any necessary adjustments to the care plan. Incorrect choices: A: Assessment - This step involves gathering information about the patient's condition and needs at the beginning of the nursing process. B: Planning - Involves setting goals and developing a plan of care based on the assessment data. C: Implementation - Involves carrying out the interventions outlined in the care plan to meet the patient's goals.
Question 4 of 5
Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?
Correct Answer: A
Rationale: The correct answer is A because continuous assessment allows for timely identification of changes in the client's condition. This is crucial for providing appropriate and timely interventions. Assessing the client only at specific times (choices B and C) may lead to missing important changes. Choice D is incorrect because assessments should not be limited to physician rounds; they should be ongoing to ensure comprehensive care.
Question 5 of 5
A client is brought to the emergency department in an unconscious condition. The client’s wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?
Correct Answer: A
Rationale: The correct answer is A: Client’s wife. She is the primary source of information as she witnessed the event firsthand and provided relevant details. In this scenario, the wife's account of the event is crucial in understanding the sequence of events leading to the client's unconscious condition. Medical documents (B), test results (C), and assessment data (D) are all secondary sources of information that may provide additional data but do not have the same level of immediacy or firsthand knowledge as the client's wife. In an emergency situation, information from a reliable eyewitness is often the most valuable initial source for healthcare providers to make critical decisions.