ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 5
Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
Correct Answer: D
Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting.
Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.
Question 2 of 5
What is the primary purpose of the implementation step in the nursing process?
Correct Answer: B
Rationale: The correct answer is B:
To carry out the plan of care. In the nursing process, implementation is the phase where nurses put the established care plan into action by delivering the interventions outlined to meet the client's needs. This step is crucial as it ensures that the care plan is executed effectively and efficiently. Establishing priorities (
A) is done during the planning phase, identifying client outcomes (
C) is part of the evaluation phase, and validating nursing diagnoses (
D) is typically done during the assessment phase, not implementation.
Question 3 of 5
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
Correct Answer: B
Rationale: The correct answer is B: Reduced sneezing. Decongestants work by constricting blood vessels in the nasal passages, reducing swelling and congestion, which in turn can lead to a decrease in sneezing. Increased salivation (choice
A) is not a typical effect of decongestants. Increased tearing (choice
C) is more commonly associated with allergies or irritants. Headache (choice
D) can be a side effect of decongestants due to their impact on blood vessels, but it does not necessarily indicate effectiveness in treating allergic rhinitis.
Question 4 of 5
Which assessment finding would prompt the Rn to suspect compartment syndrome in a patient with a long leg cast?
Correct Answer: C
Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice
A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice
B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice
D) could indicate poor circulation but is not a definitive sign of compartment syndrome.
Question 5 of 5
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Correct Answer:
Rationale:
Correct
Answer: B: Ask about the chief concerns or problems.
Rationale:
1. This step follows setting the agenda to focus on patient's main issues.
2. Allows nurse to gather essential information for effective care.
3. Builds rapport and shows patient-centered approach.
Summary of other choices:
A: Introductions are typically done at the beginning of the interview.
C: Prematurely ending the interview may hinder rapport and information gathering.
D: Administering medications is not the immediate priority after setting the agenda.