ATI RN
Pharmacology and the Nursing Process Test Bank Questions
Question 1 of 5
Which initial intervention is most appropriate for a patient who has a new onset of chest pain?
Correct Answer: B
Rationale: The correct answer is B, notifying the health care provider. This is the most appropriate initial intervention because chest pain can be a symptom of a serious medical condition like a heart attack. The health care provider needs to be informed immediately to assess the situation and provide appropriate treatment. Reassessing the patient (A) may delay crucial medical intervention. Administering pain medication (C) without knowing the cause of chest pain can be dangerous. Calling radiology for a chest x-ray (D) is not the initial step in managing new onset chest pain.
Question 2 of 5
Of the following information collected during a nursing assessment, which are subjective data?
Correct Answer: C
Rationale: Subjective data are information reported by the patient that cannot be measured or observed directly. In this case, nausea and abdominal pain are symptoms that can only be described by the patient, making them subjective data. Vomiting, pulse rate, respirations, blood pressure, pale skin, and thick toenails are all objective data, as they can be measured or observed directly by the healthcare provider. Therefore, choice C is the correct answer as it represents subjective data.
Question 3 of 5
Which of the following examples of client data needs to be validated?
Correct Answer: A
Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight. - Choice B is about interpreting physical signs, not client data validation. - Choice C involves documenting objective findings, not validating client information. - Choice D pertains to a client's complaint, not necessarily requiring validation.
Question 4 of 5
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Is written as a two-part statement. This is because a nursing diagnosis typically consists of two parts: the problem (risk for aspiration) and the related factor (reduced level of consciousness). By using a two-part statement, the nurse clearly identifies the client's current health problem and the underlying reason for it. This format helps in developing appropriate nursing interventions to address the issue. Choice B is incorrect because the nursing diagnosis does not describe the client's response to a health problem; it identifies the potential risk for aspiration. Choice C is incorrect as the diagnosis does not focus on enhancement but rather on potential harm. Choice D is incorrect because the nursing diagnosis is based on the available evidence of the client's reduced level of consciousness, which poses a risk for aspiration.
Question 5 of 5
Which of the following groups of terms best describes a nurse-initiated intervention?
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.