ATI RN
Nursing Process Practice Questions Questions
Question 1 of 5
What is the rationale for giving Mr. Franco frequent mouth care?
Correct Answer: B
Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco helps in removing dried blood when his tongue is bitten during a seizure, preventing infection and promoting oral hygiene. This is crucial in preventing complications and ensuring Mr. Franco's overall well-being.
Choice A is incorrect because thirst is not directly related to mouth care, and increasing fluids intake would address dehydration more effectively.
Choice C is incorrect as tactile stimulation may not necessarily hasten return to consciousness in this context.
Choice D is incorrect as it refers to a different issue related to mouth breathing in comatose patients, which is not the immediate concern addressed by frequent mouth care in this scenario.
Question 2 of 5
During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
Correct Answer: B
Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health.
A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment.
C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses.
D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.
Question 3 of 5
Which of the following is classified as subjective data in a nursing assessment?
Correct Answer: B
Rationale: The correct answer is B because subjective data in a nursing assessment refers to information provided by the patient, such as feelings, perceptions, and symptoms. In this case, the client stating 'I feel nauseated' represents subjective data. This type of information cannot be measured or observed directly.
A, C, and D are incorrect:
A: Heart rate of 90 beats per minute is an objective measurement that can be directly observed.
C: Blood pressure of 130/80 mmHg is also an objective measurement that can be directly observed.
D: Skin appears flushed is an objective observation that can be directly seen.
Question 4 of 5
for pain management. When applying a new system, the nurse should:
Correct Answer: A
Rationale:
Rationale:
A: Pressing the system in place for 30 to 60 seconds helps ensure proper adhesion and absorption of the medication. This step is crucial for the effectiveness of the pain management system.
B: Choosing a site on the lower torso is not necessary for applying the system. The site selection should be based on guidelines and patient preference.
C: Shaving the application site is not recommended unless specifically indicated. It is not a standard step for applying a pain management system.
D: Applying the system immediately after removal from a package may not allow the adhesive to fully activate, affecting its efficacy. It is important to follow the recommended steps for proper application.
Question 5 of 5
A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling make his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?
Correct Answer: B
Rationale: The correct answer is B: Disturbed body image. The client expressing concern about the external fixation device making his leg look ugly indicates a disturbance in how he perceives his body image. This can lead to feelings of low self-esteem and impact his overall psychological well-being. Impaired physical mobility (
A) is not the priority as the concern is not related to limitations in movement. Risk for infection (
C) may be a potential risk with the device but is not directly related to the client's current concern. Risk for social isolation (
D) is not directly indicated by the client's statement about the appearance of the leg.
Therefore, the most appropriate nursing diagnosis is Disturbed body image (
B) based on the client's expressed concern.