ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
Correct Answer: C
Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice
A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice
B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice
D) is not as reliable as urinary output for assessing fluid status.
Question 2 of 5
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get with mammograms:
Correct Answer: A
Rationale: The correct answer is A: Yearly after age 40. This recommendation aligns with the American Cancer Society guidelines that suggest women should start getting annual mammograms at age 40. This age is important as it is when the risk of breast cancer increases. Yearly screenings help in early detection and better treatment outcomes. The other choices (B, C,
D) are incorrect because they do not follow the ACS guidelines. Option B is incorrect as it does not specify an age for starting mammograms. Option C is incorrect as it suggests starting after the first menstrual period, which might be too early. Option D is incorrect as it recommends screenings every 3 years between ages 20 and 40, which is not in line with the ACS recommendation for yearly screenings after age 40.
Question 3 of 5
Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
Correct Answer: C
Rationale: The correct answer is C: Maintains skin integrity. During inguinal hernia repair surgery, maintaining skin integrity is crucial to prevent infection and ensure proper wound healing. This outcome focuses on the physical aspect of the surgery and reflects the patient's skin condition postoperatively. Verbalizing fears (
A) addresses emotional concerns, demonstrating leg exercises (
B) is related to postoperative rehabilitation, and explaining deep breathing exercises (
D) targets respiratory function, none of which directly assess the intraoperative outcome of skin integrity.
Question 4 of 5
Which of the ff points should a nurse include in the teaching plan for clients who have potential for hypovolemia?
Correct Answer: A
Rationale: The correct answer is A: Avoid alcohol and caffeine. Alcohol and caffeine are diuretics that can increase urine output, leading to fluid loss and potential hypovolemia. This step is crucial in preventing further dehydration.
Summary of incorrect choices:
B: Increasing milk and dairy products can contribute to fluid intake but does not address the prevention of hypovolemia.
C: While dried peas and beans can provide nutrients, they do not specifically address fluid intake or prevention of hypovolemia.
D: Avoiding table salt or sodium-containing foods may help in reducing fluid retention but does not directly address fluid intake to prevent hypovolemia.
Question 5 of 5
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Correct Answer: C
Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration.
Summary:
A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications.
B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue.
D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.