ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
Correct Answer: A
Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank.
Rationale:
1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway.
2. Oxygen tank:
To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted.
Summary of incorrect choices:
B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy.
C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation.
D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.
Question 2 of 5
A nurse is gathering information about a patients habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?
Correct Answer: C
Rationale: The correct answer is C: Perform a thorough nursing health history. This method is the best for gathering information about a patient's habits and lifestyle patterns because it involves asking specific questions related to the patient's daily routines, habits, and lifestyle choices. By obtaining a comprehensive health history, the nurse can gather valuable information about the patient's diet, exercise habits, sleep patterns, stress levels, substance use, and other lifestyle factors that may impact their health. Reviewing lab results (
A) may provide some information but not specifically about habits and lifestyle. Conducting a physical assessment (
B) focuses more on the patient's physical condition rather than lifestyle. Prolonging the termination phase of the interview (
D) is not a method of data collection and does not focus on gathering information about habits and lifestyle patterns.
Question 3 of 5
A patient has hand-foot syndrome related to his sickle cell anemia. What findings does the nurse expect to see as the patient is assessed?
Correct Answer: B
Rationale: The correct answer is B: Purplish discoloration of hands and feet. Hand-foot syndrome in sickle cell anemia is characterized by pain, swelling, and purplish discoloration of the hands and feet due to vaso-occlusive crisis. Unequal growth of fingers and toes (
A), webbing between fingers and toes (
C), and deformities of wrists and ankles (
D) are not typical findings associated with hand-foot syndrome in sickle cell anemia.
Question 4 of 5
Why should the nurse monitor angiotensin converting enzyme inhibitors cautiously in clients with renal or hepatic impairment and in older adults?
Correct Answer: B
Rationale: The correct answer is B: A sudden drop in BP may occur during the first 1-3 hours after the initial dose. Angiotensin converting enzyme inhibitors can cause vasodilation, leading to a reduction in blood pressure. In clients with renal or hepatic impairment and in older adults, these medications may not be cleared from the body as efficiently, increasing the risk of hypotension. Monitoring is crucial to prevent complications.
Incorrect choices:
A: A sudden raise in BP is unlikely with angiotensin converting enzyme inhibitors.
C: Angiotensin converting enzyme inhibitors do not affect body temperature.
D: Angiotensin converting enzyme inhibitors typically do not cause a sudden rise in pulse rate.
In summary, monitoring for a potential drop in blood pressure is essential in vulnerable populations when using angiotensin converting enzyme inhibitors.
Question 5 of 5
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (
Choice
C). The rationale for this is as follows:
1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management.
2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery.
3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life.
4. Posttrauma syndrome (
Choice
A) may be a consideration in the long term but is not the immediate priority. Constipation (
Choice
B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (
Choice
D) may be present but addressing pain is more urgent and directly related to the patient's current condition.