identifying the strengths and weaknesses in the plan of nursing care is part of which of the following steps for determining and fulfilling the nursin
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 2

1. Identifying the strengths and weaknesses in the nursing care plan is part of which of the following steps in determining and fulfilling the patient's nursing care needs?

Correct answer: A

Rationale: Correct. Evaluation involves assessing the effectiveness of the nursing care plan by identifying its strengths and weaknesses. This step helps in determining if the plan is meeting the patient's needs. Choice B (Planning) is incorrect because planning involves developing the nursing care plan based on the assessment of the patient's needs. Choice C (Implementation) is incorrect as it refers to putting the nursing care plan into action. Choice D (Assessment) is incorrect as assessment is the initial step in the nursing process, involving data collection and analysis to identify the patient's needs.

2. The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

Correct answer: B

Rationale: The correct answer is to assess the client for a pulse. In ventricular tachycardia, the priority is to determine if the client has a pulse. If there is no pulse, immediate initiation of CPR with chest compressions is required. Calling a code or continuing to monitor the client can delay life-saving interventions. Therefore, assessing for a pulse is the most crucial step in managing ventricular tachycardia.

3. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

Correct answer: D

Rationale: Elevating the head of the bed to 30 degrees reduces the risk of aspiration by promoting proper digestion and preventing reflux. Warming the formula to room temperature is essential to prevent discomfort and complications. Aspirating and measuring the gastric aspirate is not a recommended nursing action for monitoring enteral feeding via a nasogastric tube, as it can introduce the risk of introducing contaminants into the feeding tube. Therefore, choices A and B are incorrect, making choice D the correct answer.

4. A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?

Correct answer: C

Rationale: The correct answer is C, Tachycardia. Albuterol, a bronchodilator used to treat asthma, commonly causes tachycardia as a side effect. Flushing (choice A) is not a typical side effect of albuterol. Dyspnea (choice B) refers to difficulty breathing, which is a symptom of asthma but not a common side effect of albuterol. Hypotension (choice D) is low blood pressure, which is not a common side effect associated with albuterol use.

5. A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?

Correct answer: C

Rationale: The correct answer is C, Tachycardia. Albuterol, a bronchodilator used to treat asthma, commonly causes tachycardia as a side effect. This occurs due to the medication's stimulatory effect on beta-2 adrenergic receptors. Flushing (Choice A) is not a common side effect of albuterol. Dyspnea (Choice B) refers to difficulty breathing, which is a symptom albuterol aims to alleviate. Hypotension (Choice D) is not typically associated with albuterol use; instead, albuterol can lead to an increase in blood pressure.

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