ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 5
A febrile patient�s fluid output is in excess of normal because of diaphoresis. The nurse should plan fluid replacement based on the knowledge that insensible losses in an afebrile person are normally not greater than:
Correct Answer: C
Rationale: The correct answer is C (600ml/24hr) because insensible fluid losses in an afebrile person are typically around 600ml per 24 hours. Insensible losses include water lost through the skin as sweat and through the lungs during respiration. These losses are not easily quantifiable but are estimated to be around 600ml/day in normal circumstances. Choices A, B, and D are incorrect because they are either too low (A and B) or too high (D) compared to the normal range of insensible fluid losses. Selecting C as the correct answer is based on the understanding of physiological principles related to fluid balance and normal body functions.
Question 2 of 5
After reviewing the database, the nurse discovers that the patient�s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
Correct Answer: C
Rationale: Step 1: Safety First - The nurse's priority is patient safety. Without vital signs, medication administration can be unsafe. Step 2: Accountability - The nurse must ensure accurate and timely vital signs recording before making clinical decisions. Step 3: Delegation - Asking the NAP to record vital signs aligns with their role and helps maintain a reliable record. Step 4: Proactive Approach - By having the NAP record vital signs, the nurse can make informed decisions based on accurate data. Summary: A: Incorrect - Proceeding with medications without vital signs can risk patient safety. B: Incorrect - Waiting to review vital signs later can delay necessary interventions. D: Incorrect - Omitting vital signs is negligent and compromises patient care.
Question 3 of 5
A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Equipment. The nurse needs to ensure that necessary equipment is available to carry out interventions effectively and safely. Without the right equipment, the nurse may not be able to provide appropriate care. Safe environment (B) is important but not a resource that the nurse makes sure is available. Confidence (C) is a personal attribute and not a resource. Assistive personnel (D) are individuals who can help but are not resources that the nurse ensures are available.
Question 4 of 5
A nurse conducts an assessment and notes that the client has abnormal breath sounds, a productive cough, and cyanotic lips. How should the nurse categorize these findings?
Correct Answer: B
Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data. Summary: - A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse. - C: Secondary data are information obtained from other sources, not directly from the client. - D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.
Question 5 of 5
Nursing care for a patient who is experiencing a convulsive seizure includes all of the following except:
Correct Answer: B
Rationale: The correct answer is B because inserting a mouth gag during a convulsive seizure can obstruct the airway and pose a choking hazard. Step-by-step rationale: A: Loosening clothing helps improve ventilation. C: Positioning on the side with head flexed forward prevents aspiration. D: Providing privacy is important for patient dignity and confidentiality. B is incorrect as it can be harmful.
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