ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 5
Other signs of hypovolemia includes all of the following except:
Correct Answer: C
Rationale: The correct answer is C because decreased pulse rate and widened pulse pressure are not signs of hypovolemia. In hypovolemia, the body tries to compensate by increasing the heart rate and narrowing the pulse pressure to maintain adequate blood flow. A is incorrect as dry mucous membranes and soft eyeballs are signs of dehydration. B is incorrect as increased hematocrit and hemoglobin are indicators of hemoconcentration in hypovolemia. D is incorrect as increased lethargy and confusion can be seen in severe hypovolemia due to poor perfusion of vital organs.
Question 2 of 5
Which method of data collection will the nurse use to establish a patient’s database?
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather comprehensive data about the patient's health status, including vital signs, physical appearance, and potential health issues. It provides valuable information for developing an individualized care plan. Reviewing literature (
A) is important but not for establishing a patient's database. Checking orders (
B) and ordering medications (
D) are part of the treatment process and do not directly contribute to establishing the initial patient database.
Question 3 of 5
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?
Correct Answer: A
Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario.
Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.
Question 4 of 5
A client has been diagnosed with type 1 diabetes mellitus. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?
Correct Answer: A
Rationale: The correct answer is A: “You’ll need more insulin when you exercise or increase your food intake.” In type 1 diabetes, exercise and increased food intake can lead to increased glucose levels, requiring more insulin to maintain blood sugar control. Increasing physical activity can enhance insulin sensitivity, necessitating adjustments in insulin dosage.
Choices B, C, and D are incorrect as they do not align with the physiological response in type 1 diabetes. B suggests needing less insulin when exercising, which is inaccurate as physical activity can lower blood sugar levels. C implies needing less insulin with increased food intake, which is incorrect as more food can lead to higher glucose levels. D suggests needing more insulin when decreasing food intake, which is not necessarily true as lower food intake can result in lower glucose levels.
Question 5 of 5
The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?
Correct Answer: A
Rationale: The correct answer is A: Human Needs (Maslow) model. The nurse is using a systematic approach based on Maslow's Hierarchy of Needs, which includes physiological, safety, love/belonging, esteem, and self-actualization needs. This model organizes assessment data by prioritizing these universal life requirements.
Incorrect choices:
B: Functional Health Patterns model - This model focuses on 11 functional health patterns, not the hierarchy of universal life requirements.
C: Human Response Patterns model - This model focuses on the individual's response to stressors, not prioritizing universal life requirements.
D: Body System model - This model focuses on assessing specific body systems, not the holistic approach of addressing all life requirements.