ATI RN
Nursing Process Questions Questions
Question 1 of 5
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient�s daughter runs out of the room and says, �My mother can�t talk. Somebody help!� Which response by the nurse is best?
Correct Answer: B
Rationale: The correct answer is B. The nurse should do a quick assessment to confirm the change in the patient's status, then notify the RN or physician. This is the best response because the nurse needs to immediately assess the patient's condition to ensure prompt intervention if needed. By confirming the change in the patient's status, the nurse can provide the necessary information to the healthcare team for appropriate evaluation and management. The other choices are incorrect because: A does not address the urgency of the situation, C involves unnecessary delay by waiting for the speech therapist, and D is not appropriate as the nurse should be the one assessing and notifying the healthcare team.
Question 2 of 5
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
Correct Answer: C
Rationale: Objective data are measurable and observable facts obtained through physical examination or diagnostic tests. In this case, "Respirations 16" is a quantifiable and observable measurement, making it objective data. It is not influenced by personal interpretation or feelings. The other choices, such as "States 'doesn't feel good'", "Reports a headache", and "Nauseated" are subjective data because they are based on the patient's feelings or experiences, which can vary depending on individual perception and interpretation, making them less reliable for making clinical decisions. By focusing on objective data like "Respirations 16", the nurse can provide a more accurate assessment of the patient's condition.
Question 3 of 5
Choose the condition that exhibits blood values with a low pH and a high PCO :
Correct Answer: A
Rationale: Correct Answer: A: Respiratory acidosis Rationale: 1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO? and decreased pH. 2. Low pH indicates acidosis, and high PCO? indicates respiratory component. 3. Metabolic acidosis (B) results from non-respiratory causes. 4. Respiratory alkalosis (C) is characterized by high pH and low PCO?. 5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.
Question 4 of 5
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue. A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty. B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition. C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem. In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.
Question 5 of 5
Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
Correct Answer: B
Rationale: The correct answer is B because monitoring for swelling and heaviness of legs is essential in preventing falls, which can be caused by conditions like edema or circulatory issues. Swollen or heavy legs can affect mobility and balance, increasing the risk of falls. This intervention helps identify potential issues early and implement preventive measures. Choice A is incorrect as monitoring for chest pain and LDL levels pertains more to cardiovascular health than fall prevention. Choice C is incorrect because monitoring postural changes in BP is important for managing hypertension, not necessarily for preventing falls. Choice D is incorrect as monitoring temperature for mild fever is more related to identifying infections rather than preventing falls.
Similar Questions
Join Our Community Today!
Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for ATI-RN and 3000+ practice questions to help you pass your ATI-RN exam.
Subscribe for Unlimited Access