ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
A 19-year-old student develops symptoms of respiratory alkalosis related to an anxiety attack. Which nursing intervention is appropriate?
Correct Answer: B
Rationale: The correct answer is B: Have him breathe into a paper bag. Breathing into a paper bag helps increase the carbon dioxide levels in the blood, which can help reverse respiratory alkalosis caused by hyperventilation during an anxiety attack. This intervention helps to normalize the blood pH and alleviate symptoms. Incorrect choices: A: Making sure oxygen is administered as ordered is not appropriate for respiratory alkalosis due to hyperventilation. Oxygen therapy can worsen the condition by further reducing carbon dioxide levels. C: Placing the student in a semi-fowler's position does not directly address the primary issue of respiratory alkalosis and anxiety-induced hyperventilation. D: Coughing and deep breathing exercises may exacerbate the hyperventilation and worsen the respiratory alkalosis rather than alleviate the symptoms.
Question 2 of 5
How many liters per minute of oxygen should be administered to the patient with emphysema?
Correct Answer: A
Rationale: The correct answer is A: 2 L/min. In emphysema, there is impaired gas exchange due to damaged lung tissue, resulting in decreased oxygen levels. Administering too high a flow rate can lead to oxygen toxicity. The standard oxygen therapy for emphysema is 1-2 L/min to maintain oxygen saturation without causing harm. Higher flow rates like 10 L/min (B) and 6 L/min (C) are excessive and can lead to oxygen toxicity. 95 L/min (D) is dangerously high and not suitable for oxygen therapy in emphysema. Therefore, A is the correct choice for safe and effective oxygen administration in emphysema.
Question 3 of 5
Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?
Correct Answer: B
Rationale: The correct answer is B: Renal failure. Acute respiratory distress syndrome (ARDS) can lead to hypoxemia and respiratory acidosis, causing decreased perfusion to the kidneys and potentially leading to renal failure. Monitoring for signs of renal failure, such as decreased urine output and elevated creatinine levels, is crucial in managing clients with ARDS. Incorrect choices: A: Chest wall bulging is not a common complication of ARDS. It may be seen in conditions like tension pneumothorax. C: Difficulty swallowing is not a typical complication of ARDS. It may be seen in neurological conditions or esophageal disorders. D: Orthopnea is not a direct complication of ARDS. It is more commonly associated with heart failure or pulmonary edema.
Question 4 of 5
As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Anaphylaxis is a severe allergic reaction that can lead to airway constriction and difficulty breathing, resulting in wheezing. Wheezing is a common symptom of anaphylaxis due to bronchospasm and airway swelling. Dermatitis (A) is a skin reaction, sinusitis (B) is inflammation of the sinuses, and delirium (C) is a state of mental confusion, which are not typical symptoms of anaphylaxis. Wheezing is a critical symptom in anaphylaxis as it indicates potential airway compromise and the need for immediate medical intervention.
Question 5 of 5
Which of the ff would help a client with an allergic skin reaction to reduce itching and maintain skin intact? Choose all that apply
Correct Answer: D
Rationale: The correct answer is D. Wearing cotton gloves, especially during sleep, helps reduce itching by preventing scratching, which can further irritate the skin. Cotton is a breathable fabric that reduces friction and irritation. A: Humidifying the environment may help in some cases, but it doesn't directly address the itching or maintaining skin integrity. B: Avoiding a skin lubricant is not recommended as it can help moisturize the skin and reduce itching. C: Bathing with a bar soap that contains lye can be harsh and drying, exacerbating the skin reaction.