ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse’s analysis are:
Correct Answer: C
Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (
Choice
A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (
Choice
B) is contradictory to the body's compensatory response to maintain perfusion.
Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.
Question 2 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 3 of 5
A 57-year old patient had a right lower lobectomy. The nurse should initiate this action when the patient arrives from the Post Anesthesia Care Unit:
Correct Answer: A
Rationale: The correct answer is A: immediately administer pain relief. After a lobectomy, the patient may experience significant pain due to the surgical incision and chest tube insertion. Providing prompt pain relief is crucial to ensure the patient's comfort and prevent complications such as shallow breathing or limited mobility. This action will also aid in the patient's early recovery and promote better outcomes.
Choice B (keep patient in semi-fowler's position) is not the priority upon arrival from the Post Anesthesia Care Unit as pain management takes precedence.
Choice C (turn client every hour) is important for preventing complications but is not the immediate action required upon arrival.
Choice D (notify the family to report patient's condition) is important but not as urgent as providing pain relief to the patient.
Question 4 of 5
The patient asks the nurse, “What is hypertension?” Which of the following is the best response to explain hypertension?
Correct Answer: D
Rationale: The correct answer is D because hypertension is primarily determined by peripheral vascular resistance, which refers to the resistance in the blood vessels that the heart must overcome to pump blood effectively. This is a key factor in the development of high blood pressure.
Choice A is incorrect as it simplifies the concept to just the pumping action of the heart.
Choice B is incorrect because hypertension is not just about having high readings on separate occasions but rather a sustained elevation in blood pressure.
Choice C is incorrect as stress, activity, and emotions can influence blood pressure but are not the sole determinants of hypertension.
Question 5 of 5
Ms. CC’s laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?
Correct Answer: C
Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia.
Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration.
Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance.
Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.