performing and supervising therapeutic and preventive procedures that have been planned for a patient is part of which of the following steps for det
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 4

1. Performing and supervising therapeutic and preventive procedures that have been planned for a patient is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

Correct answer: C

Rationale: The correct answer is C: Implementation. Implementation in nursing care involves the actual performance and supervision of the planned therapeutic and preventive procedures for a patient. Evaluation (choice A) is the step where the effectiveness of the interventions is assessed. Planning (choice B) is the phase where the nursing care plan is developed based on the assessment. Assessment (choice D) is the initial step in the nursing process, involving data collection and analysis to determine the patient's needs.

2. What causes hepatic encephalopathy?

Correct answer: A

Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body. Ammonia, a byproduct of protein metabolism, normally gets converted to urea in the liver for excretion. However, in liver dysfunction, such as cirrhosis, the liver cannot effectively convert ammonia to urea, leading to its accumulation in the body and subsequently causing hepatic encephalopathy. Choices B, C, and D are incorrect as they do not directly relate to the pathophysiology of hepatic encephalopathy.

3. When is aspirin most effective when taken?

Correct answer: A

Rationale: Aspirin is best absorbed on an empty stomach to maximize its effectiveness. Taking it with cold water helps in its quick absorption. Option B is incorrect because taking aspirin on a full stomach can delay its absorption. Option C is incorrect as fruit juice may not provide the ideal conditions for absorption. Option D is incorrect as taking aspirin first thing in the morning may not ensure an empty stomach.

4. The client is complaining of painful swallowing secondary to mouth ulcers. Which statement by the client indicates appropriate management?

Correct answer: D

Rationale: The correct answer is D. Avoiding irritants like spicy foods, tobacco, and alcohol is crucial in managing mouth ulcers as they can further irritate and worsen the condition. Choice A is incorrect as using a soft-bristle toothbrush may still cause discomfort. Choice B is incorrect as alcohol-containing mouthwashes can be irritating. Choice C is incorrect as swallowing antifungal solution meant for topical use is not appropriate and can be harmful.

5. Which of the following statements does NOT apply to a nursing plan of care?

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.

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