ATI RN
Nursing Process Practice Questions Questions
Question 1 of 5
The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body’s normal flora, the nurse must monitor the client for:
Correct Answer: D
Rationale: The correct answer is D: Diarrhea. Antibiotics can disrupt the normal balance of gut bacteria, leading to diarrhea. This occurs due to the overgrowth of harmful bacteria in the intestines. Monitoring for diarrhea is crucial to prevent dehydration and further complications. Platelet dysfunction (
A), stomatitis (
B), and oliguria/dysuria (
C) are not typically associated with the disruption of normal flora by antibiotics. These symptoms are more likely related to other conditions or side effects of medications, making them incorrect choices in this scenario.
Question 2 of 5
Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
Correct Answer: D
Rationale: The correct answer is D: high calorie high protein. In COPD exacerbation, the body requires extra calories and protein for energy and muscle strength. High-calorie foods help combat weight loss and fatigue. High-protein foods aid in muscle repair and maintenance. Low-fat low-cholesterol (
A) is not ideal as healthy fats are needed. Low-sodium (
B) is not necessary unless there is concurrent heart failure. Bland soft diet (
C) is not suitable as it does not provide enough calories and protein needed for COPD exacerbation.
Question 3 of 5
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B - Focus on the patient's presenting situation. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan.
Now, let's analyze the other choices:
A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue.
C: Making accurate interpretations of the data comes after data collection, so it is not the first step.
D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific and relevant data.
Question 4 of 5
Severe and extensive hemolysis causes which of the ff?
Correct Answer: B
Rationale: Severe and extensive hemolysis leads to the release of large amounts of hemoglobin into the bloodstream, causing hemoglobinemia. This can result in hemoglobinuria, leading to acute renal failure and ultimately shock. Shock is the correct answer as it is a severe consequence of extensive hemolysis. Leg ulcers (
A) may occur in conditions like peripheral arterial disease. Priapism (
C) is unrelated to hemolysis. Compromised growth (
D) is not a common consequence of hemolysis.
Question 5 of 5
.A client complains of urinary discomfort and a burning sensation while urinating. A urethral smear shows evidence of urethritis, and the client is prescribed antibiotics and instructed to drink 2-3 L of water daily. For which of the ff reasons is the client advised to drink the specified amount of water?
Correct Answer: B
Rationale:
Step 1: Antibiotics are prescribed to treat urethritis, indicating a bacterial infection in the urinary tract.
Step 2: Increasing water intake (2-3 L daily) promotes renal blood flow, dilutes urine, and helps flush out bacteria from the urinary tract, aiding in the elimination of infection.
Step 3: Adequate hydration helps prevent the formation of concentrated urine, reducing the risk of recurrent urinary tract infections.
Step 4:
Therefore, choice B is correct as it directly addresses the underlying cause of the client's symptoms.
Summary:
Choices A, C, and D are incorrect as they do not directly target the bacterial infection causing the urinary discomfort. Drinking water will not specifically help with incontinence, eliminate odors, or provide pain relief.