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. The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up?

A. Client with chronic kidney disease and serum creatinine of 1.6 mg/dL
B. Client with diabetes mellitus and a glycosylated hemoglobin A1c (HbA1c) of 7.0%
C. Client with heart failure and a B-type natriuretic peptide (BNP) of 140 pg/mL
D. Client who is male and has anemia with hemoglobin of 16.5 g/dL and hematocrit of 45%

Correct answer: B

Rationale: An HbA1c of 7.0% in a client with diabetes mellitus indicates poor long-term glucose control, necessitating immediate follow-up. Choice A, chronic kidney disease with a serum creatinine of 1.6 mg/dL, though concerning, does not indicate an immediate need for follow-up. Choice C, heart failure with a BNP of 140 pg/mL, may require monitoring but not immediate follow-up. Choice D, a male client with anemia and normal hemoglobin and hematocrit levels, does not warrant immediate attention based on the provided information.

3. 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 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.

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

A. Evaluation
B. Planning
C. Implementation
D. Assessment

Correct answer: A

Rationale: The correct answer is A: Evaluation. Evaluation in nursing care involves assessing the effectiveness of the care plan, identifying strengths, weaknesses, and areas for improvement. This step helps ensure that the patient's needs are being met appropriately. Planning (choice B) involves developing the care plan based on the assessment data. Implementation (choice C) is the step where the care plan is put into action. Assessment (choice D) is the initial step in the nursing process that involves collecting and analyzing data about the patient's health status.

5. A client is prescribed lisinopril (Zestril) for the treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should inform him about which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors?

A. Constipation
B. Dizziness
C. Headache
D. B, C

Correct answer: D

Rationale: The correct answer is D: 'Dizziness' and 'Headache'. ACE inhibitors like lisinopril are known to cause these common side effects due to their blood pressure-lowering effects. Choice A, 'Constipation', is not a common adverse effect associated with ACE inhibitors. While constipation can be a side effect of some medications, it is not typically seen with ACE inhibitors. Therefore, options A and B are incorrect choices.