ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 5
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
Correct Answer: D
Rationale: The correct answer is D. Asking the patient about usual sleep patterns and the onset of having difficulty resting is the best action for the nurse to take. This allows the nurse to gather more information and assess if there is a possible correlation between the leg cast and the restless sleep. It is important to consider all aspects of the patient's condition and not dismiss any symptoms. Choice A is incorrect because telling the patient to just focus on the leg and cast disregards the patient's concerns about restless sleep. Choice B is incorrect as simply documenting the information without further assessment does not address the patient's issue. Choice C is incorrect as postponing a thorough assessment to the next shift may delay necessary intervention for the patient's sleep problem.
Question 2 of 5
The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
Correct Answer: C
Rationale: The correct answer is C: Interdependent. In this scenario, the nurse performed an intervention for a collaborative problem, which involves working together with other healthcare professionals to address the issue. Interdependent interventions require collaboration and communication among healthcare team members to achieve the best outcomes for the patient. Choice A (Dependent Nursing) refers to interventions that require an order from a healthcare provider. Choice B (Independent) involves nursing actions that the nurse can initiate without the need for a healthcare provider's order. Choice D (Physician-initiated) specifically denotes interventions initiated by a physician without direct involvement from the nurse. In this case, the nurse's intervention for a collaborative problem aligns with the definition of interdependent intervention, making it the correct choice.
Question 3 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 4 of 5
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan. B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer. C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer. D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.
Question 5 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.