ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
A nurse is conducting a nursing health history. Which component will the nurse address?
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for care. By focusing on the patient's expectations, the nurse can provide patient-centered care and tailor interventions to meet the patient's specific needs.
A: Nurse's concerns - While it is important for the nurse to consider their own concerns, the primary focus should be on the patient's needs and expectations.
C: Current treatment orders - This is important information to gather, but it does not directly address the patient's expectations or preferences.
D: Nurse's goals for the patient - The nurse should work collaboratively with the patient to establish goals that align with the patient's expectations and preferences, rather than imposing their own goals.
Question 2 of 5
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
Correct Answer: A
Rationale: The correct answer is A. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process.
B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully.
C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood.
D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.
Question 3 of 5
Olympic gymnast Ms. Slovenski sufferd a great fall and suffered a great fall and fractured her femur. Approximately after 20 hours in the hospital she became dyspneic, tachypneic, and with scattered crackles in her lung fields. She is coughing up large amounts of thick, white sputum. The nurse correctly interprets this as:
Correct Answer: C
Rationale: The correct answer is C: fat embolism syndrome related to femur fracture. Fat embolism syndrome occurs when fat globules enter the bloodstream and travel to the lungs, causing respiratory distress. In this case, the patient's femur fracture likely led to fat embolism, explaining her dyspnea, tachypnea, crackles, and thick sputum.
Choices A, B, and D do not align with the patient's presentation and history, making them incorrect.
Choice A suggests smoke inhalation, which is not supported by the scenario.
Choice B mentions pneumonia from bedrest, which is not a common complication of immobility.
Choice D proposes hypovolemic shock from multiple trauma, which does not explain the respiratory symptoms and sputum production observed in the patient.
Question 4 of 5
Which of the ff. interventions can help minimize complications related to Hypercalcemia?
Correct Answer: A
Rationale:
Step-by-step rationale for why choice A is correct:
1. Hypercalcemia can lead to dehydration due to increased urine output.
2. Encouraging 3 to 4 L of fluid daily helps prevent dehydration and promote renal excretion of excess calcium.
3. Adequate hydration reduces the risk of kidney stones and other complications associated with hypercalcemia.
Summary of why other choices are incorrect:
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Choice B (bed rest) does not directly address hypercalcemia complications.
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Choice C (cough and deep breathe) is unrelated to managing hypercalcemia.
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Choice D (apply heat to painful areas) does not address the underlying cause of hypercalcemia or its complications.
Question 5 of 5
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?
Correct Answer: B
Rationale: The correct answer is B: "Take ferrous sulfate and the antacid at least 2 hours apart."
Rationale:
1. Iron absorption is decreased in the presence of antacids due to decreased gastric acidity.
2. Antacids can bind to iron and reduce its absorption.
3. Taking them 2 hours apart allows for optimal iron absorption without interference from the antacid.
4. Taking them together (choice
A) would decrease iron absorption.
5. Avoiding antacids altogether (choice
C) may not be necessary if spaced apart appropriately.
6. Taking them 1 hour apart (choice
D) may still lead to decreased iron absorption due to antacid interference.