ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 5
Which action should the nurse take first during the initial phase of implementation?
Correct Answer: D
Rationale: The correct answer is D: Reassess the patient. During the initial phase of implementation, the nurse should first reassess the patient to gather current data and evaluate the effectiveness of previous interventions. This step ensures that the nurse has updated information to make informed decisions about the patient's care. A: Determining patient outcomes and goals should come after reassessment. B: Prioritizing nursing diagnoses is important but should be based on current assessment data. C: Evaluating interventions should be done after implementing them and giving them time to take effect.
Question 2 of 5
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe. 2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention. 3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue. 4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking. Summary: - Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking. - Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database. - Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation. - Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.
Question 3 of 5
A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment?
Correct Answer: D
Rationale: The correct answer is D because interviewing a client suspected of being a victim of abuse involves critical thinking in assessment by gathering relevant information, analyzing the situation, and making informed decisions. This activity helps identify potential risks and ensures the client's safety. On the other hand, options A and C involve implementing orders and diagnosing conditions, respectively, which are more related to clinical decision-making rather than assessment. Option B focuses on education, which is not directly linked to assessment activities.
Question 4 of 5
A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling make his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?
Correct Answer: B
Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being. Rationale: 1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move. 2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg. 3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.
Question 5 of 5
Which of the following outcomes is correctly written?
Correct Answer: C
Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.