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
ANS: D
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
ANS: B
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 1
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 decision-making 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
ANS: A
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
ANS: A, B, C, D
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
ANS: A
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.
2. 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.
ANS: B
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.
3. 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?
3
Administer scheduled medications assuming that the NAP would have
a. reported abnormal vital signs.
(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
ANS: D
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
ANS: B
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 1
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 decision-making 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
ANS: A
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
ANS: A, B, C, D
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
ANS: A
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.
2. 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.
ANS: B
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.
3. 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?
3
Administer scheduled medications assuming that the NAP would have
a. reported abnormal vital signs.
