ATI RN
ADPIE Nursing Process Questions Questions
Question 1 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 2 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.
Question 3 of 5
What is the primary purpose of validation as a part of assessment?
Correct Answer: D
Rationale: The primary purpose of validation in assessment is to ensure that the data collected is accurate and reliable to plan appropriate nursing care. Validation helps confirm the accuracy of data, identify inconsistencies, and ensure that the information gathered is trustworthy. By verifying the data, nurses can make informed decisions and tailor individualized care plans to meet the patient's needs effectively. Choices A, B, and C are incorrect because they do not directly relate to the purpose of validation in assessment. Choice A focuses on the identification of data, not the purpose of validation. Choice B and C pertain to communication and relationships, which are important but not the primary purpose of validation in the assessment process.
Question 4 of 5
A nurse conducts an assessment and notes that the client has abnormal breath sounds, a productive cough, and cyanotic lips. How should the nurse categorize these findings?
Correct Answer: B
Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data. Summary: - A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse. - C: Secondary data are information obtained from other sources, not directly from the client. - D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.
Question 5 of 5
A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
Correct Answer: C
Rationale: The correct answer is C: Disturbed body image related to the incision scar. This nursing diagnosis is appropriate as the client's concern about wearing a scarf post-surgery indicates a potential disturbance in body image due to the visible scar. The nurse should address the client's emotional response and offer support to help cope with the change in appearance. A: Risk for impaired physical mobility due to surgery - This choice is not directly related to the client's worry about wearing a scarf and focuses more on physical limitations post-surgery. B: Ineffective denial related to poor coping mechanisms - This choice does not address the specific body image concern expressed by the client. D: Risk of injury related to surgical outcomes - This choice does not address the client's emotional response to the scar and focuses on physical safety risks instead.