Preview Extract
ATI PN MED SURG PROCTORED EXAM
(Detail Solutions)
1. A nurse who is caring for a patient with a pressure ulcer applies the recommended
dressing according to hospital policy. Which standard is the nurse following?
a. Fairness
b. Intellectual standards
c. Independent reasoning
d. Institutional practice guidelines
Answer: D
Rationale:
The standards of professional responsibility that a nurse tries to achieve are the standards
cited in Nurse Practice Acts, institutional practice guidelines (hospital/facility policy), and
professional organizations’ standards of practice (e.g., The American Nurses Association
Standards of Professional Performance). Intellectual standards are guidelines or principles
for rational thought. Fairness and independent reasoning are two examples of critical
thinking attitudes that are designed to help nurses make clinical decisions.
2. A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the
registered nurse revise?
a. Patient’s outcomes for learning
b. Nurse’s assumptions about hospital discharge
c. Identification of several actual health problems
d. Documentation of patient’s ability to meet the goal
Answer: B
Rationale:
The nurse should not assume when a patient is going to be discharged and document this
information in a plan of care. Making assumptions is not an example of a critical thinking
skill. The purpose of the nursing process is to diagnose and treat human responses (e.g.,
patient symptoms, need for knowledge) to actual or potential health problems. Use of the
process allows nurses to help patients meet agreed-on outcomes for better health. The
patient’s outcomes, having several actual health problems, and a description of the patient’s
abilities to meet the goal are all appropriate to document in the nursing plan of care.
3. In which order will the nurse use the nursing process steps during the clinical decisionmaking process?
1. Evaluating goals
2. Assessing patient needs
3. Planning priorities of care
4. Determining nursing diagnoses
5. Implementing nursing interventions
a. 2, 4, 3, 5, 1
b. 4, 3, 2, 1, 5
c. 1, 2, 4, 5, 3
d. 5, 1, 2, 3, 4
Answer: A
Rationale:
The American Nurses Association developed standards that set forth the framework
necessary for critical thinking in the application of the five-step nursing process:
assessment, diagnosis, planning, implementation, and evaluation.
MULTIPLE RESPONSE
1. Which findings will alert the nurse that stress is present when making a clinical decision?
(Select all that apply.)
a. Tense muscles
b. Reactive responses
c. Trouble concentrating
d. Very tired feelings
e. Managed emotions
Answer: A, B, C, D
Rationale:
Learn to recognize when you are feeling stressed—your muscles will tense, you become
reactive when others communicate with you, you have trouble concentrating, and you feel
very tired. Emotions are not managed when stressed.
2. 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?
a. Completes a comprehensive database
b. Identifies pertinent nursing diagnoses
c. Intervenes based on priorities of patient care
d. Determines whether outcomes have been achieved
Answer: A
Rationale:
The assessment phase of the nursing process involves data collection to complete a thorough
patient database and is the first phase. Identifying nursing diagnoses occurs during the
diagnosis phase or second phase. The nurse carries out interventions during the
implementation phase (fourth phase), and determining whether outcomes have been
achieved takes place during the evaluation phase (fifth phase) of the nursing process.
3. A nurse is using the problem-oriented approach to data collection. Which action will the
nurse take first?
a. Complete the questions in chronological order.
b. Focus on the patient’s presenting situation.
c. Make accurate interpretations of the data.
d. Conduct an observational overview.
Answer: B
Rationale:
A problem-oriented approach focuses on the patient’s current problem or presenting
situation rather than on an observational overview. The database is not always completed
using a chronological approach if focusing on the current problem. Making interpretations
of the data is not data collection. Data interpretation occurs while appropriate nursing
diagnoses are assigned. The question is asking about data collection.
4. 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?
a. Administer scheduled medications assuming that the NAP would have reported abnormal
vital signs.
b. Have the patient transported to the radiology department for a scheduled x-ray, and
review vital signs upon return.
c. Ask the NAP to record the patient’s vital signs before administering medications.
d. Omit the vital signs because the patient is presently in no distress.
Answer: C
Rationale:
The nurse should ask the nursing assistive personnel to record the vital signs for review
before administering medicines or transporting the patient to another department. The nurse
should not make assumptions when providing high-quality patient care, and omitting the
vital signs is not an appropriate action.
5. The nurse is gathering data on a patient. Which data will the nurse report as objective
data?
a. States “doesn’t feel good”
b. Reports a headache
c. Respirations 16
d. Nauseated
Answer: C
Rationale:
Objective data are observations or measurements of a patient’s health status, like
respirations. Inspecting the condition of a surgical incision or wound, describing an
observed behavior, and measuring blood pressure are examples of objective data. States
“doesn’t feel good,” reports a headache, and nausea are all subjective data. Subjective data
include the patient’s feelings, perceptions, and reported symptoms. Only patients provide
subjective data relevant to their health condition.
6. A patient expresses fear of going home and being alone. Vital signs are stable and the
incision is nearly completely healed. What can the nurse infer from the subjective data?
a. The patient can now perform the dressing changes without help.
b. The patient can begin retaking all of the previous medications.
c. The patient is apprehensive about discharge.
d. The patient’s surgery was not successful.
Answer: C
Rationale:
Subjective data include expressions of fear of going home and being alone. These data
indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is
not an appropriate sign that a patient is able to perform dressing changes independently. An
order from a health care provider is required before a patient is taught to resume previous
medications. The nurse cannot infer that surgery was not successful if the incision is nearly
completely healed.
7. Which method of data collection will the nurse use to establish a patient’s database?
a. Reviewing the current literature to determine evidence-based nursing actions
b. Checking orders for diagnostic and laboratory tests
c. Performing a physical examination
d. Ordering medications
Answer: C
Rationale:
You will learn to conduct different types of assessments: the patient-centered interview
during a nursing health history, a physical examination, and the periodic assessments you
make during rounding or administering care. A nursing database includes a physical
examination. The nurse reviews the current literature in the implementation phase of the
nursing process to determine evidence-based actions, and the health care provider is
responsible for ordering medications. The nurse uses results from the diagnostic and
laboratory tests to establish a patient database, not checking orders for tests.
8. A nurse is gathering information about a patient’s habits and lifestyle patterns. Which
method of data collection will the nurse use that will best obtain this information?
a. Carefully review lab results.
b. Conduct the physical assessment.
c. Perform a thorough nursing health history.
d. Prolong the termination phase of the interview.
Answer: C
Rationale:
The nursing health history also includes a description of a patient’s habits and lifestyle
patterns. Lab results and physical assessment will not reveal as much about the patient’s
habits and lifestyle patterns as the nursing health history. Collecting data is part of the
working phase of the interview.
9. 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?
a. Consider cultural differences during this assessment.
b. Ask the patient to make eye contact to determine her affect. Continue with the interview
and document that the patient is
c. depressed.
d. Notify the health care provider to recommend a psychological evaluation.
Answer: A
Rationale:
To conduct an accurate and complete assessment, consider a patient’s cultural background.
This nurse needs to practice culturally competent care and appreciate the cultural
differences. Assuming that the patient is depressed or in need of a psychological evaluation
or to force eye contact is inappropriate.
10. A nurse has already set the agenda during a patient-centered interview. What will the
nurse do next?
a. Begin with introductions.
b. Ask about the chief concerns or problems.
c. Explain that the interview will be over in a few minutes.
d. Tell the patient “I will be back to administer medications in 1 hour.”
Answer: B
Rationale:
After setting the agenda, the nurse should conduct the actual interview and proceed with
data collection, such as asking about the patient’s current chief concerns or problems.
Introductions occur before setting the agenda. Begin an interview by introducing yourself
and your position and explaining the purpose of the interview. Your aim is to set an agenda
for how you will gather information about a patient’s current chief concerns or problems.
The termination phase includes telling the patient when the interview is nearing an end.
Telling the patient that medications will be given later when the nurse returns would
typically take place during the termination phase of the interview.
