ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
Arthur, a 66-year old client for pneumonia has a temperature ranging from 39° to 40° C with periods of diaphoresis. Which of the following interventions by Nurse Carlos would be a priority?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (
B) is important for hygiene but not the priority. Fluid intake (
C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (
D) may be necessary but addressing oxygenation takes precedence in this case.
Question 2 of 5
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient’s plan of care?
Correct Answer: C
Rationale: The correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance.
A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit.
B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake.
D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.
Question 3 of 5
The majority of lumbar disc herniations occur at the level of:
Correct Answer: B
Rationale: The correct answer is B: L4-L5. This is because the L4-L5 intervertebral disc segment experiences the highest amount of mechanical stress and mobility in the lumbar spine, making it more prone to herniation. Additionally, nerve roots at this level innervate the lower extremities, making it a common site for symptoms such as sciatica.
Choices A, C, and D are incorrect because herniations at those levels are less common due to lower mechanical stress and mobility compared to L4-L5.
Question 4 of 5
A client is brought to the emergency department in an unconscious condition. The client’s wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?
Correct Answer: A
Rationale: The correct answer is A: Client’s wife. She is the primary source of information as she witnessed the event firsthand and provided relevant details. In this scenario, the wife's account of the event is crucial in understanding the sequence of events leading to the client's unconscious condition. Medical documents (
B), test results (
C), and assessment data (
D) are all secondary sources of information that may provide additional data but do not have the same level of immediacy or firsthand knowledge as the client's wife. In an emergency situation, information from a reliable eyewitness is often the most valuable initial source for healthcare providers to make critical decisions.
Question 5 of 5
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery.
Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently.
Choice B is incorrect as resuming medications is not related to the patient's fear of being alone.
Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.