which of the following statements does not apply to a nursing plan of care

ATI RN

ATI RN Custom Exams Set 1

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

A. It contains short-term goals
B. It is developed by the patient's physician
C. It must be continually evaluated
D. It contains long-range goals

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 patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.

2. Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task 'Know what your soldiers are doing during duty hours'?

A. Accountability
B. Personal/professional development
C. Individual training
D. Military appearance/physical condition

Correct answer: A

Rationale: The correct answer is A: Accountability. Accountability involves knowing what individuals are doing during duty hours, ensuring they are responsible and answerable for their actions. Personal/professional development (choice B) refers to enhancing one's skills and knowledge, individual training (choice C) focuses on specific training needs, and military appearance/physical condition (choice D) pertains to the physical presentation and fitness of individuals, not directly related to knowing what they are doing during duty hours.

3. Which situation(s) are classified as natural disasters?

A. Blizzards
B. Blizzards, Volcanic eruptions
C. Volcanic eruptions
D. Structural collapse

Correct answer: B

Rationale: Blizzards and volcanic eruptions are classified as natural disasters because they are caused by natural forces beyond human control. In contrast, structural collapses are typically a result of man-made factors, making them not classified as natural disasters. Therefore, the correct answer is B.

4. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?

A. Explain to the client that it is too early to have an injection for pain
B. Call the practitioner, report the client’s symptoms, and obtain further orders
C. Reposition the client for greater comfort and turn on the television as a distraction
D. Prepare the injection and administer it to the client early because of the severe pain

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to call the practitioner, report the client’s symptoms, and obtain further orders. The client's symptoms, including severe abdominal pain, pallor, perspiration, thready rapid pulse, and feeling faint, are indicative of potential complications like internal bleeding, which require immediate medical evaluation. Explaining to the client that it is too early for pain medication or repositioning the client for comfort are not appropriate actions given the severity of the symptoms. Administering the injection early without consulting the practitioner can be dangerous and may worsen the client's condition.

5. What is the correct amount of specimen to collect when collecting a stool specimen for testing purposes?

A. The nurse scoop the specimen specifically at the site
B. She took around 1 inch of specimen or a teaspoonful
C. Ask the client to call her for the specimen after the
D. Ask the client to defecate in a bedpan, Secure a

Correct answer: B

Rationale: When collecting a stool specimen, the nurse should usually take about 1 inch of the specimen or a teaspoonful for testing purposes. This amount is sufficient for laboratory analysis and helps ensure accurate results. It is important for the nurse to follow the proper procedure for specimen collection to maintain accuracy in diagnostic testing. Choices A, C, and D are incorrect because they do not provide the correct information on the amount of specimen needed for stool specimen collection.