Nursing Process Test Bank

Questions 68

ATI RN

ATI RN Test Bank

Nursing Process Test Bank Questions

Question 1 of 5

While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client�s chart. Which of the following actions clearly demonstrates assessing?

Correct Answer: C

Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being. A: The nurse bathing the client is not an action of assessment but rather a task related to providing care. B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition. D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.

Question 2 of 5

Which of the ff. nursing diagnoses is the focus of care for a patient with hypertension?

Correct Answer: D

Rationale: The correct answer is D: Deficient knowledge. This nursing diagnosis is appropriate because educating the patient about hypertension, its management, lifestyle modifications, and medication adherence is crucial in improving outcomes. Activity intolerance (A) and impaired physical mobility (B) are not typically primary focuses for hypertension but may be secondary concerns. Ineffective airway clearance (C) is unrelated to hypertension. Therefore, D is the most relevant option for addressing the patient's needs.

Question 3 of 5

Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?

Correct Answer: B

Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.

Question 4 of 5

A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?

Correct Answer: B

Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety. Incorrect responses: A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety. C: Explaining that assistance will always be available may not address the immediate need for assessment and safety. D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.

Question 5 of 5

Hemodynamic monitoring by means of a multilumen pulmonary artery catheter can provide detailed information about:

Correct Answer: D

Rationale: The correct answer is D because a multilumen pulmonary artery catheter can provide detailed information about preload, afterload, and cardiac output. Preload refers to the volume of blood in the ventricles at the end of diastole, afterload is the resistance the heart has to overcome to eject blood, and cardiac output is the amount of blood pumped by the heart per minute. This catheter allows for direct measurement of these parameters by monitoring pressures in the pulmonary artery. Choices A, B, and C are incorrect individually as they do not encompass the full range of information that can be obtained with a multilumen pulmonary artery catheter.

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