ATI RN
ATI Nur 237 Fundamentals Quiz Questions
Extract:
Question 1 of 5
A nurse receives a patient who has been in the intensive care unit for three weeks after a motor vehicle accident. The nurse assesses the patient who reports fatigue. The nurse notes increased heart rate and decreased blood pressure when the patient moves from lying to sitting. When developing the plan of care, what problem label should the nurse use?
Correct Answer: B
Rationale: The correct answer is B: Activity Intolerance. The patient's symptoms of fatigue, increased heart rate, and decreased blood pressure upon position change indicate an inability to tolerate physical activity. This is common in patients who have been immobile for an extended period, such as those in the ICU. By selecting this problem label, the nurse can focus on interventions to gradually increase the patient's activity level to improve tolerance.
A: Risk for alteration in skin integrity - This choice is not supported by the patient's symptoms and presentation.
C: Risk for Infection - The patient's symptoms do not indicate a risk for infection.
D: Deficient Fluid volume - The patient's symptoms are not indicative of fluid volume deficit.
Question 2 of 5
A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?
Correct Answer: D
Rationale: The correct answer is D: Assess the patient's blood pressure to determine if the medication is effective. This is the priority during the evaluation phase because it directly assesses the effectiveness of the new antihypertensive medication in managing the patient's hypertension. By monitoring the patient's blood pressure, the nurse can evaluate if the medication is achieving the desired therapeutic effect.
Reviewing the patient's medication history for potential drug interactions (
A) is important but not a priority during the evaluation phase. Educating the patient about potential side effects (
B) is also crucial but can be done after assessing the medication's effectiveness. Documenting the patient's baseline blood pressure (
C) is essential but should have been done before starting the medication, not during the evaluation phase.
Question 3 of 5
The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?
Correct Answer: C
Rationale: The correct answer is C: Get patient input when making the plan. This is crucial because involving the patient ensures that the discharge plan is tailored to their specific needs and preferences. It promotes autonomy and increases adherence to the plan. Involving the multidisciplinary team (
A) and family members (
B) are important but secondary to the patient's input. Starting planning at admission (
D) is beneficial, but without the patient's input, the plan may not be as effective.
Question 4 of 5
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
Correct Answer: D
Rationale: The correct answer is D: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, and modesty rather than a sign of depression or dishonesty. By being aware of and respecting cultural differences, the nurse can build rapport and trust with the patient. Asking the patient to make eye contact (
Choice
A) may make her uncomfortable and hinder effective communication. Notifying the health care provider for a psychological evaluation (
Choice
B) is premature and could potentially lead to unnecessary interventions. Continuing with the interview and assuming the patient is depressed (
Choice
C) without considering cultural factors can lead to misinterpretation and inappropriate care.
Question 5 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: C
Rationale: The correct answer is C because completing a comprehensive database is part of the assessment phase, which is the first phase of the nursing process. Assessment involves gathering information about the patient's health status. Option A pertains to the evaluation phase, where outcomes are assessed. Option B relates to the diagnosis phase, where nursing diagnoses are identified. Option D refers to the implementation phase, where interventions are carried out based on established priorities.