ATI Fundamentals: Nursing
Process, Prioritization &
Clinical Judgment Review
1.
A nurse is assessing a client who reports abdominal pain. Which
action should the nurse take first?
A. Administer the prescribed analgesic
B. Ask the client to rate the pain
C. Document the client's report
D. Notify the provider
Answer: B. Ask the client to rate the pain
Rationale: Assessment precedes interventions. Determining the pain
intensity provides objective information needed to plan appropriate
care.
2.
Which finding is an example of subjective data?
A. Blood pressure is 148/86 mm Hg
B. Respiratory rate is 24/min
C. Client reports feeling dizzy
D. Skin is cool and pale
Answer: C. Client reports feeling dizzy
Rationale: Subjective data are symptoms or perceptions reported by
the client.
,3.
A nurse obtains a blood pressure of 88/54 mm Hg. Which component
of the nursing process does this finding represent?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B. Assessment
Rationale: Collecting physiological measurements is part of the
assessment phase.
4.
Which statement represents a nursing diagnosis?
A. Pneumonia
B. Acute kidney injury
C. Impaired gas exchange related to alveolar-capillary membrane
changes
D. Chest x-ray demonstrates infiltrates
Answer: C. Impaired gas exchange related to alveolar-capillary
membrane changes
Rationale: A nursing diagnosis identifies a client's response to an
actual or potential health problem.
5.
A nurse identifies “Risk for falls” for an older adult receiving
antihypertensive medication. Which type of diagnosis is this?
A. Actual
B. Risk
C. Syndrome
D. Medical
,Answer: B. Risk
Rationale: A risk diagnosis describes a vulnerability to developing a
problem rather than an existing problem.
6.
Which action demonstrates the planning phase of the nursing
process?
A. Measuring oxygen saturation
B. Identifying impaired mobility
C. Establishing a goal for ambulation
D. Assisting the client to ambulate
Answer: C. Establishing a goal for ambulation
Rationale: Planning involves establishing measurable goals and
selecting interventions.
7.
A nurse reassesses a client after administering oxygen. Which
nursing-process phase is demonstrated?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: D. Evaluation
Rationale: Evaluation determines whether the client's response
indicates that goals have been met.
8.
Which goal is written correctly?
A. Client will feel better.
B. Client will improve mobility.
, C. Client will ambulate 50 meters with assistance by 1600.
D. Nurse will encourage walking three times daily.
Answer: C. Client will ambulate 50 meters with assistance by 1600.
Rationale: An effective goal is specific, measurable, attainable,
relevant, and time limited.
9.
A client has a nursing diagnosis of “Acute pain.” Which outcome is
most measurable?
A. Client will have less pain.
B. Client will appear comfortable.
C. Client will report pain of 3/10 or less within 1 hour.
D. Client will receive pain medication as prescribed.
Answer: C. Client will report pain of 3/10 or less within 1 hour.
Rationale: The outcome contains an observable measurement and a
specific time frame.
10.
A nurse determines that a client's goal has not been met. What
should the nurse do next?
A. Discontinue all interventions
B. Reassess the client and revise the plan as appropriate
C. Document the goal as achieved
D. Notify the provider immediately
Answer: B. Reassess the client and revise the plan as appropriate
Rationale: When goals are unmet, the nurse reassesses contributing
factors and modifies the plan when necessary.
Section 2: Prioritization
Process, Prioritization &
Clinical Judgment Review
1.
A nurse is assessing a client who reports abdominal pain. Which
action should the nurse take first?
A. Administer the prescribed analgesic
B. Ask the client to rate the pain
C. Document the client's report
D. Notify the provider
Answer: B. Ask the client to rate the pain
Rationale: Assessment precedes interventions. Determining the pain
intensity provides objective information needed to plan appropriate
care.
2.
Which finding is an example of subjective data?
A. Blood pressure is 148/86 mm Hg
B. Respiratory rate is 24/min
C. Client reports feeling dizzy
D. Skin is cool and pale
Answer: C. Client reports feeling dizzy
Rationale: Subjective data are symptoms or perceptions reported by
the client.
,3.
A nurse obtains a blood pressure of 88/54 mm Hg. Which component
of the nursing process does this finding represent?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B. Assessment
Rationale: Collecting physiological measurements is part of the
assessment phase.
4.
Which statement represents a nursing diagnosis?
A. Pneumonia
B. Acute kidney injury
C. Impaired gas exchange related to alveolar-capillary membrane
changes
D. Chest x-ray demonstrates infiltrates
Answer: C. Impaired gas exchange related to alveolar-capillary
membrane changes
Rationale: A nursing diagnosis identifies a client's response to an
actual or potential health problem.
5.
A nurse identifies “Risk for falls” for an older adult receiving
antihypertensive medication. Which type of diagnosis is this?
A. Actual
B. Risk
C. Syndrome
D. Medical
,Answer: B. Risk
Rationale: A risk diagnosis describes a vulnerability to developing a
problem rather than an existing problem.
6.
Which action demonstrates the planning phase of the nursing
process?
A. Measuring oxygen saturation
B. Identifying impaired mobility
C. Establishing a goal for ambulation
D. Assisting the client to ambulate
Answer: C. Establishing a goal for ambulation
Rationale: Planning involves establishing measurable goals and
selecting interventions.
7.
A nurse reassesses a client after administering oxygen. Which
nursing-process phase is demonstrated?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: D. Evaluation
Rationale: Evaluation determines whether the client's response
indicates that goals have been met.
8.
Which goal is written correctly?
A. Client will feel better.
B. Client will improve mobility.
, C. Client will ambulate 50 meters with assistance by 1600.
D. Nurse will encourage walking three times daily.
Answer: C. Client will ambulate 50 meters with assistance by 1600.
Rationale: An effective goal is specific, measurable, attainable,
relevant, and time limited.
9.
A client has a nursing diagnosis of “Acute pain.” Which outcome is
most measurable?
A. Client will have less pain.
B. Client will appear comfortable.
C. Client will report pain of 3/10 or less within 1 hour.
D. Client will receive pain medication as prescribed.
Answer: C. Client will report pain of 3/10 or less within 1 hour.
Rationale: The outcome contains an observable measurement and a
specific time frame.
10.
A nurse determines that a client's goal has not been met. What
should the nurse do next?
A. Discontinue all interventions
B. Reassess the client and revise the plan as appropriate
C. Document the goal as achieved
D. Notify the provider immediately
Answer: B. Reassess the client and revise the plan as appropriate
Rationale: When goals are unmet, the nurse reassesses contributing
factors and modifies the plan when necessary.
Section 2: Prioritization
