ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 5
A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
Correct Answer: D
Rationale: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly.
A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function.
B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system.
C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.
Question 2 of 5
What is the primary purpose of validation as a part of assessment?
Correct Answer: D
Rationale: The primary purpose of validation in assessment is to ensure that the data collected is accurate and reliable to plan appropriate nursing care. Validation helps confirm the accuracy of data, identify inconsistencies, and ensure that the information gathered is trustworthy. By verifying the data, nurses can make informed decisions and tailor individualized care plans to meet the patient's needs effectively.
Choices A, B, and C are incorrect because they do not directly relate to the purpose of validation in assessment.
Choice A focuses on the identification of data, not the purpose of validation.
Choice B and C pertain to communication and relationships, which are important but not the primary purpose of validation in the assessment process.
Question 3 of 5
The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse’s best response?
Correct Answer: A
Rationale: Rationale for Correct Answer (
A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby.
Summary of Incorrect
Choices:
B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors.
C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby.
D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.
Question 4 of 5
Total parenteral nutrition (TPN) is ordered for an adult client. Which nutrient is not likely to be in the solution?
Correct Answer: C
Rationale: The correct answer is C: trace minerals. TPN solutions typically include dextrose for energy, electrolytes for maintaining fluid balance, and amino acids for protein synthesis. Trace minerals are not typically included in TPN solutions as they are only required in small amounts and can be toxic in excess.
Therefore, it is not likely to be in the solution. The other choices (A, B,
D) are essential components of TPN solutions necessary for meeting the nutritional needs of the patient.
Question 5 of 5
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
Correct Answer: B
Rationale: The correct answer is B. Placing the patient on the right side with support to the back, pillows for body alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled is most appropriate for a patient with right-sided paralysis following a stroke. This position helps prevent contractures by maintaining proper alignment and positioning of the limbs. Placing the washcloth to curl the fingers helps prevent hand contractures. Supporting the back and keeping the hips slightly flexed also helps prevent pressure ulcers and maintains proper body alignment.
Choice A is incorrect because tightly holding a rolled washcloth may cause discomfort and restrict blood flow.
Choice C is incorrect because placing the patient on the back with a pillow under the knees does not address the specific needs of a patient with right-sided paralysis.
Choice D is incorrect because lying on the back with trochanter rolls and a footboard does not address the specific needs of a patient with right-sided paralysis and may not prevent contractures effectively.