ATI Fundamentals: Chapter 7 (Nursing Process) Flashcards
A nurse is assessing/ collecting data from a client. Sort the findings into objective or subjective data.
a. RR is even and unlabored at 22/min
b. The client’s partner states, “They had burning leg pain after walking 10 minutes.”
c. The client’s pain rating is 3 on a scale of 0 to 10.
d. The client’s skin is consistent with genetic background, warm, and dry.
e. An assistive personnel reports that the client walked with a limp.
Objective: A, D, E
Subjective: B, C
Objective data includes information the nurse can feel, see, hear, or smell, through observation or physical measurement such as RR, skin color, temperature, and characteristics, and observation that the client is walking with a limp. Subjective data includes a client’s feelings, perceptions, and descriptions of health status, such as pain level, description of pain, and contributing factors to pain.
A charge nurse is talking with a newly licensed nurse about nursing interventions that require a providers prescription and nursing interventions that are nurse-initiated. Sort the following interventions into nurse-initiated or provider-initiated.
a. Inserting a nasogastric tube to relieve gastric distention.
b. Showing a client how to use progressive muscle relaxation.
c. Performing a daily bath after the evening meal.
d. Repositioning a client every 2 hr to reduce pressure injury risk.
e. Writing a prescription for morphine PRN for pain.
Nurse-initiated: B, C, D
Provider-initiated: A, E
A nurse caring for a client who is two days postoperative and has not achieved satisfactory pain relief. According to the nursing process, which of the following actions should the nurse take first?
a. Check the client to determine the reason for inadequate pain relief.
b. Determine whether the change in plan reduces the client’s pain.
c. Change the plan of care to provide a different method of pain relief.
d. Educate the client about the plan of care for managing the pain.
a. CORRECT: When prioritizing hypotheses, and using the nursing process, the first action the nurse should take is to check the client to determine the reason for inadequate pain relief. The nurse should collect objective and subjective data to determine a new plan of care to promote comfort and reduce the client’s pain.
A charge nurse is observing a newly licensed nurse care for a client who is postoperative and reports pain. Match the actions of the newly licensed nurse with the nursing process.
1. Assessment/ data collection
2. Analysis/ diagnosis/ data collection
3. Planning
4. Implementation
5. Evaluation
a. The newly licensed nurse documents that the client’s pain is causing the client to take shallow breaths and could lead to complications such as atelectasis.
b. The newly licensed nurse administered the pain med to the client.
c. The newly licensed nurse asks the client to rate the severity of the pain on a scale 0 to 10.
d. The newly licensed nurse checks the client 40 min after administering the pain med to determine the effectiveness of the med in relieving the client’s pain.
e. The newly licensed nurse determines the client is due to receive the pain med and prepares to administer a dose to the client.
1: C
2: A
3: E
4: B
5: D
A charge nurse is discussing the nursing process with a newly licensed nurse who is caring for a client. Match the following statements by the newly licensed nurse with each step of the nursing process.
1. Assessment/ data collection
2. Analysis/ diagnosis/ data collection
3. Planning
4. Implementation
5. Evaluation
a. “I will determine the most important client problems that we should address.”
b. “I will review the past medical history in the client’s medical record to obtain more information about the client.”
c. “I will ask the client if their nausea is resolved.”
d. “I will review objective and subjective client data to identify potential client problem.”
e. “I will administer prescriptions from the provider.”
1: B
2: D
3: A
4: E
5: C
