ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
A post-TURP patient experiences dribbling following removal of his catheter. Which action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Teach him to perform Kegel's exercises 10 to 20 times per hour. This is the appropriate action because Kegel's exercises help strengthen the pelvic floor muscles, which can improve urinary control and reduce dribbling post-TURP. Restricting fluid intake (
A) is not necessary and may lead to dehydration. Reinserting the Foley catheter (
C) is not recommended as it can increase the risk of infection. Reassuring the patient (
D) without providing any intervention is not addressing the issue. Teaching Kegel's exercises is the most effective and non-invasive approach to manage post-TURP dribbling.
Question 2 of 5
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
Correct Answer: B
Rationale: The correct answer is B: The waiting area with the television turned off. This setting provides a quiet environment, minimizing distractions for the patient with a hearing deficit. It allows the nurse to communicate effectively by speaking clearly and facing the patient directly. Option A is incorrect because a closed door may not be enough to reduce background noise. Option C is incorrect as pain medication may affect the patient's ability to concentrate. Option D is incorrect because the occupational therapist working on leg exercises may create additional noise and distractions.
Question 3 of 5
When caring for Mr. Reyes, the nurse should assess for
Correct Answer: B
Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues.
A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario.
C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness.
D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.
Question 4 of 5
A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to
Correct Answer: A
Rationale: The correct answer is A because the Nursing Interventions Classification (NI
C) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care.
Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses.
Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions.
Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.
Question 5 of 5
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?
Correct Answer: D
Rationale: The correct answer is D: Sitting at a 45-degree angle to the bed. This position allows the nurse to have a clear view of the client and maintain good communication. Sitting at a 45-degree angle enables the nurse to observe the client's facial expressions, body language, and interact effectively. Standing at the end of the bed (
A) limits the nurse's view and communication. Standing at the side of the bed (
B) may obstruct the nurse-client interaction. Sitting at least six feet away (
C) creates unnecessary distance and hinders effective communication.