ATI RN
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Question 1 of 5
Which six phases are included in the nursing process?
Correct Answer: D
Rationale: The correct answer is D. The nursing process consists of Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation. Assessment involves gathering data about the patient's health status. Diagnosis is the identification of the patient's health problems. Outcome Identification sets goals for resolving these problems. Planning involves developing a care plan. Implementation is the execution of the care plan. Evaluation assesses the effectiveness of the care provided. Choices A, B, and C are incorrect: A: Treatment and client outcome are not individual phases in the nursing process. B: Admission and discharge planning are not standalone phases in the nursing process. C: Expected outcome is not a phase, and assessment is missing from the sequence.
Question 2 of 5
A nurse is caring for a patient who is post-operative following a total knee replacement. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. This is a priority intervention because early ambulation helps prevent complications such as blood clots and respiratory issues. It also promotes circulation and aids in the recovery process. Administering pain medication (B) is important but not the top priority. Providing wound care and dressing changes (C) is necessary but can be done after ensuring the patient's mobility. Monitoring for signs of infection (D) is also crucial, but promoting early ambulation takes precedence in this scenario to prevent complications.
Question 3 of 5
Which type of assessment promotes critical thinking and clustering of similar data?
Correct Answer: A
Rationale: The correct answer is A: Body systems. This type of assessment promotes critical thinking by organizing data systematically based on different body systems, allowing for clustering of similar data and identification of patterns. Comprehensive assessments (B) may include body systems but lack the focused approach of promoting critical thinking. Head to toe assessments (C) are systematic but may not encourage clustering of data. Emergency assessments (D) prioritize immediate interventions rather than promoting critical thinking or clustering of data.
Question 4 of 5
What is the first priority when caring for a client with a gunshot wound to the chest?
Correct Answer: C
Rationale: The correct answer is C: Apply an airtight dressing. This is the first priority because it helps prevent air from entering the chest cavity, which can cause a tension pneumothorax. A tension pneumothorax can rapidly lead to respiratory distress and cardiac arrest. Applying an airtight dressing helps stabilize the condition until further medical intervention can be provided. Incorrect choices: A: Performing needle decompression is not the first priority as it is indicated for a tension pneumothorax once it has developed, not as a preventive measure. B: Applying a sterile dressing is important but not the first priority when dealing with a gunshot wound to the chest as sealing the wound to prevent air entry is more critical. D: Monitoring the client's ECG is not the first priority in this situation as addressing the potential tension pneumothorax takes precedence over monitoring the client's heart rhythm.
Question 5 of 5
Which action should not be performed when fetal distress is indicated?
Correct Answer: C
Rationale: The correct answer is C: decrease maternal fluids. When fetal distress is indicated, decreasing maternal fluids helps prevent further stress on the fetus by reducing the volume of amniotic fluid. This can help improve blood flow to the placenta and oxygen delivery to the baby. Increasing maternal fluids (choice A) can worsen the situation by potentially increasing amniotic fluid volume and further compromising fetal oxygenation. Administering oxygen (choice B) is important to improve oxygen supply to the fetus. Turning the mother (choice D) can help relieve pressure on the baby but is not the primary action when fetal distress is indicated.
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