ATI RN
Nursing Process Questions Questions
Question 1 of 5
Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
Correct Answer: A
Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.
Question 2 of 5
A client reports difficulty breathing, stating, 'I can’t catch my breath.' What is the most appropriate action for the nurse to take?
Correct Answer: A
Rationale: The correct answer is A because measuring oxygen saturation will provide objective data to assess the client's respiratory status accurately. This step is crucial in identifying the severity of the client's breathing difficulty and determining the appropriate intervention. Encouraging deep breathing exercises (B) may worsen the client's condition if there is an underlying respiratory problem. Simply documenting the client's statement (C) without immediate action can delay necessary interventions. Providing oxygen without further assessment (D) can be harmful if the client's oxygen saturation is already high. Overall, option A is the most appropriate as it involves a proactive and evidence-based approach to address the client's reported breathing difficulty.
Question 3 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 because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.
Question 4 of 5
Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards?
Correct Answer: B
Rationale: Correct Answer: B (State Nurse Practice Acts) Rationale: State Nurse Practice Acts outline the legal scope of nursing practice, including standards for setting priorities, identifying client outcomes, and selecting evidence-based nursing interventions. These laws are specific to nursing practice, ensuring that nurses follow guidelines tailored to their profession. Nurses must adhere to these standards to provide safe and effective care. Summary of Incorrect Choices: A: Professional physicians' organizations - While physicians' organizations may provide guidelines for medical practice, they do not set standards specific to nursing practice. C: The Joint Commission - The Joint Commission focuses on accreditation for healthcare organizations, not setting standards for nursing practice. D: The Agency for Health Care Research and Quality - AHRQ conducts research and provides evidence-based information but does not establish standards for nursing practice.
Question 5 of 5
A client’s blood glucose levels remain elevated despite adherence to the prescribed treatment plan. What is the nurse’s best action?
Correct Answer: A
Rationale: The correct answer is A because reassessing the client's diet, medication, and lifestyle habits allows the nurse to identify any factors contributing to the elevated blood glucose levels. By identifying possible issues, the nurse can make necessary adjustments to the treatment plan to better manage the client's condition. Increasing medication dosage without understanding the root cause may lead to adverse effects. Simply documenting the elevated levels without taking proactive measures does not address the problem. Notifying the client's family is not the nurse's first action; the focus should be on assessing and addressing the client's needs.