ATI RN
Nursing Process NCLEX Questions Questions
Question 1 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 step is crucial for identifying the patient's needs and developing a holistic care plan. Choice B is incorrect because identifying nursing diagnoses typically occurs in the second phase (diagnosis). Choice C is incorrect as intervening based on care priorities happens in the third phase (planning and implementation). Choice D is incorrect as determining outcomes achieved is part of the final phase (evaluation).
Question 2 of 5
A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client’s priorities for care using which of the following?
Correct Answer: A
Rationale: The correct answer is A, assessment skills. Assessing the client's current condition, including respiratory status, is crucial in determining priorities for care in asthma management. By utilizing assessment skills, the nurse can gather essential information to identify the client's immediate needs and develop an individualized care plan. Nursing books (B) can provide general information but do not provide real-time data on the client's current status. Client's records (C) may contain historical information but may not reflect the client's current condition. Supervisor's advice (D) is important but should supplement rather than replace the nurse's assessment skills in determining immediate care priorities.
Question 3 of 5
The nurse is caring for a patient with HIV who has diarrhea. Which of the following would be most therapeutic to teach the patient to avoid in the diet to reduce diarrhea?
Correct Answer: C
Rationale: The correct answer is C: Raw fruits and vegetables. Patients with HIV and diarrhea should avoid raw fruits and vegetables due to their high fiber content, which can exacerbate diarrhea symptoms. Fiber can increase bowel movements and worsen diarrhea. Therefore, avoiding raw fruits and vegetables can help reduce diarrhea. Choice A (Potassium-rich food) is not the best answer because potassium-rich foods are important for patients with HIV to maintain electrolyte balance. Choice B (Liquid nutritional supplements) can actually be beneficial in providing essential nutrients to patients with HIV. Choice D (Frozen products) is not directly related to diarrhea management in patients with HIV.
Question 4 of 5
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? This matches with the "Location" component of the PQRST. This question helps determine the specific area where the pain is occurring, providing crucial information for diagnosis and treatment. This step is important in identifying potential underlying issues related to the pain. Summary of other choices: B: What causes the pain? - This question relates to the "Provocation/Palliation" component, not the location. C: Does it come and go? - This question corresponds to the "Quality" component, focusing on the characteristics of the pain. D: What does the pain feel like? - This question aligns with the "Severity" component, concentrating on the intensity of the pain.
Question 5 of 5
A client is brought to the emergency department unconscious after a fall. What is the primary source of information in this case?
Correct Answer: A
Rationale: The correct answer is A: Client's spouse. In the case of an unconscious client, the spouse is the primary source of information about the client's medical history, medications, allergies, and recent events. This information is crucial for providing appropriate care. Medical records may not be immediately accessible. Diagnostic tests provide limited historical information. Nursing assessment relies on the client's condition, which may not provide comprehensive information.
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