ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
Which of the ff. positions is best for a chest drainage system when the patient is being transported by wheelchair?
Correct Answer: A
Rationale: The correct answer is A because hanging the chest drainage system on the top of the wheelchair backrest ensures that the system remains upright and secured during transportation, reducing the risk of accidental disconnection or leakage. Placing it on the patient's feet (
B), hanging it with the IV pole (
C), or placing it in the patient's lap (
D) can lead to potential complications such as pulling or kinking the drainage tubing, increasing the risk of infection or injury to the patient.
Question 2 of 5
The physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guerin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:
Correct Answer: B
Rationale: The correct answer is B: Hematuria. Bacillus Calmette-Guerin (BCG) is commonly used in the treatment of bladder cancer. It works by stimulating the immune system to attack and destroy cancer cells in the bladder. One of the common side effects of BCG instillations is hematuria, which is the presence of blood in the urine. This can occur due to irritation of the bladder lining by the BCG solution, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware of what to expect during treatment.
A: Renal calculi - BCG therapy is not commonly associated with the formation of renal calculi.
C: Delayed ejaculation - Delayed ejaculation is not a common side effect of BCG therapy.
D: Impotence - Impotence is not a common side effect of BCG therapy.
Question 3 of 5
. Which of the following instructions should be included in the teaching plan for a client requiring insulin?
Correct Answer: D
Rationale: The correct answer is D: Draw up clear insulin first when mixing two types of insulin in one syringe. This is important because mixing insulin requires drawing up the clear (short-acting) insulin first to prevent contamination. This ensures accurate dosing and prevents clouding of the insulin. Drawing up cloudy insulin first can lead to inaccurate dosing and potential mixing errors. Administering insulin after the first meal (choice
A) is not the focus of this question. Administering insulin at a 45-degree angle into the deltoid muscle (choice
B) is not recommended for insulin injections. Vigorously shaking the vial of insulin before withdrawal (choice
C) can cause bubbles and affect the accuracy of the dose.
Question 4 of 5
A patient complains of tingling in his fingers. He has positive Trousseau’s and Chvostek’s signs. He says that he feels depressed. Choose the most likely serum calcium (Ca ) value for this patient:
Correct Answer: A
Rationale: The correct answer is A: 11mg/dl. This patient is likely experiencing hypocalcemia, indicated by positive Trousseau's and Chvostek's signs. These signs suggest neuromuscular irritability due to low calcium levels. A serum calcium level of 11mg/dl is higher than normal, indicating possible hyperparathyroidism causing high calcium levels.
Choices B, C, and D are lower than normal, which would exacerbate symptoms rather than alleviate them.
Question 5 of 5
Which of the following settings is most therapeutic for an agitated head-injured patient?
Correct Answer: B
Rationale: The correct answer is B. A semiprivate room with one or two consistent caregivers is the most therapeutic setting for an agitated head-injured patient. Here's the rationale:
1. Consistency: Having one or two consistent caregivers provides the patient with a stable and familiar environment, which can help reduce agitation.
2. Privacy: A semiprivate room offers more privacy compared to a day room or a ward, which can help minimize external stimuli and promote relaxation.
3. Individualized care: In a semiprivate room, caregivers can focus more on the specific needs of the patient, leading to better management of agitation.
4. Reduced distractions: Being in a semiprivate room minimizes distractions and noise, which can be overwhelming for an agitated head-injured patient.
Summary:
A, C, and D are incorrect because they do not offer the same level of consistency, privacy, individualized care, and reduced distractions as a semiprivate room with one