ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
Correct Answer: B
Rationale: The correct answer is B because it indicates a confrontational and possibly disrespectful attitude towards the nurse. This can hinder effective communication and collaboration. A: Shows understanding of hallucinations. C: Demonstrates assistance to the father. D: Reflects consideration for the father's needs. B is incorrect as it does not promote positive interaction.
Question 2 of 5
Which of the ff. type of eyedrops does the nurse understand is given to constrict the pupil, permitting aqueous humor to flow around the lens?
Correct Answer: C
Rationale: The correct answer is C: Myotic. Myotic eyedrops constrict the pupil, allowing aqueous humor to flow around the lens. Myotic agents, such as pilocarpine, work by stimulating the sphincter muscle of the iris. Osmotic eyedrops (
A) reduce intraocular pressure, mydriatic eyedrops (
B) dilate the pupil, and cycloplegic eyedrops (
D) paralyze the ciliary muscle to prevent accommodation.
Question 3 of 5
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow’s hierarchy of basic human needs, is appropriate for what level of needs?
Correct Answer: A
Rationale: The correct answer is A: Physiologic. Impaired Gas Exchange pertains to the basic physiological need for oxygenation, which is fundamental for survival. Maslow's hierarchy states that physiological needs are the most fundamental and must be met before progressing to higher-level needs. Safety, love and belonging, and self-actualization are higher-level needs compared to physiological needs.
Therefore, Impaired Gas Exchange aligns with the physiological level of needs in Maslow's hierarchy.
Question 4 of 5
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. In this scenario, the nurse needs to analyze the data and identify the patient's problem, which is urinary retention due to abnormal kidney function and decreased oral intake. This step is crucial to develop a care plan. Planning (
B) comes after diagnosis, where interventions are determined. Implementation (
C) involves executing the care plan, and Evaluation (
D) is the final step to assess the effectiveness of interventions.
Question 5 of 5
In the presence of coma or unconsciousness, the major therapeutic measure includes:
Correct Answer: A
Rationale: The correct answer is A: Maintenance of a clear airway. In cases of coma or unconsciousness, ensuring a clear airway is crucial to prevent respiratory complications and maintain oxygenation. This involves positioning the patient correctly, suctioning if necessary, and monitoring breathing.
Choice B, good nursing care, is too broad and does not address the immediate priority of airway management.
Choice C, retention of a catheter, is irrelevant to managing a coma or unconsciousness.
Therefore, the correct therapeutic measure in this scenario is to focus on maintaining a clear airway to support respiratory function.