ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
Correct Answer: D
Rationale: The correct answer is D (Lamb and peaches) because lamb is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Peaches are high in vitamin C, which enhances iron absorption. Shrimp and tomatoes (
A) have some iron but are not as rich in iron as lamb. Cheese and bananas (
B) are not significant sources of iron. Lobster and squash (
C) also do not provide as much iron as lamb. Overall, the combination of heme iron from lamb and vitamin C from peaches makes them the most suitable choices for an anemic client requiring iron therapy.
Question 2 of 5
A client with neuromuscular disorder is receiving intensive nursing care. The client is likely to face the risk for impaired skin integrity. Which of the ff must the nurse ensure to prevent skin breakdown in the client?
Correct Answer: B
Rationale: The correct answer is B: Use pressure relieving devices when the client is in bed. This is because pressure ulcers are a common risk for individuals with neuromuscular disorders due to immobility. Pressure relieving devices such as special mattresses or cushions help redistribute pressure and prevent skin breakdown.
Incorrect choices:
A: Preventing strenuous exercises is not directly related to preventing skin breakdown in this case.
C: Placing the client in Fowler's position may be beneficial for respiratory issues but does not directly address skin integrity.
D: Avoiding daily baths with soaps may lead to poor hygiene and does not specifically address the risk of skin breakdown.
Question 3 of 5
Why are older adults with heart and blood vessel diseases susceptible to thrombophlebitis?
Correct Answer: B
Rationale: The correct answer is B: IV drugs and chemicals. Thrombophlebitis is inflammation of a vein with blood clot formation, commonly caused by irritants like IV drugs. Impaired mobility (
C) and compromised circulation (
D) are risk factors for thrombophlebitis, but not specific to older adults with heart and blood vessel diseases. A is incorrect as not all choices apply in this scenario.
Question 4 of 5
A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? “Evaluative measures are multiple-page documents used to evaluate nurse
Correct Answer: B
Rationale: The correct answer is B because evaluative measures in nursing refer to the assessment data used to determine if patients have achieved their expected outcomes and goals. This is crucial in evaluating the effectiveness of the care provided.
Choice A is incorrect because it defines evaluative measures as multiple-page documents, which is not accurate.
Choice C is incorrect as it focuses on the progression of a nurse's skill level rather than patient outcomes.
Choice D is incorrect as it defines evaluative measures as objective views of completing nursing interventions, which is too narrow of a definition.
Question 5 of 5
A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
Correct Answer: C
Rationale: The correct answer is C, Disturbed body image related to the incision scar. This is the most appropriate nursing diagnosis as the client's concern about wearing a scarf around his neck post-surgery indicates a potential disturbance in body image. This diagnosis addresses the client's emotional response to physical changes, which is common in surgical patients.
Choice A is incorrect because impaired physical mobility is not directly related to the client's worry about wearing a scarf.
Choice B is incorrect as ineffective denial does not directly address the client's specific concern about body image.
Choice D is also incorrect as the risk of injury is not the primary issue in this scenario; it is more about the client's perception of their appearance post-surgery.
In summary, the client's worry about wearing a scarf post-surgery indicates a disturbance in body image, making choice C the most appropriate nursing diagnosis.