ATI RN
Nursing Process Practice Questions Questions
Question 1 of 5
A 27-year old adult is admitted for treatment of Crohn’s disease. Which information is most significant when the nurse assesses nutritional health?
Correct Answer: A
Rationale: The correct answer is A: Anthropometric measurements. This includes height, weight, and body mass index, which are crucial indicators of the nutritional status of a patient with Crohn's disease. It helps assess malnutrition, muscle wasting, and overall nutritional health. Dry skin (B), bleeding gums (C), and facial rubor (D) are not direct indicators of nutritional health in a patient with Crohn's disease. Dry skin may indicate dehydration, bleeding gums may suggest poor oral hygiene or gum disease, and facial rubor may be a sign of inflammation but are not specific to nutritional status.
Question 2 of 5
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
Correct Answer: A
Rationale: The correct answer is A: status of client’s tetanus immunization. It is critical because an open fracture poses a risk of infection, and tetanus prophylaxis is necessary to prevent tetanus infection. Tetanus is caused by a bacterium commonly found in soil and can enter the body through open wounds. Assessing the client's tetanus immunization status helps determine the need for a tetanus booster to prevent potential complications. Incorrect choices: B: Current blood alcohol level - While relevant to the situation, the priority in this case is preventing infection from the open fracture. C: Support systems available at home to assist with care - Important for discharge planning but not the immediate priority. D: Last time client voided - Not critical in this scenario compared to preventing infection from the open fracture.
Question 3 of 5
In the operating room, personnel should be responsible for ensuring cleanliness, proper temperature, humidity, and lighting. Who carries those responsibilities?
Correct Answer: A
Rationale: The correct answer is A: circulating nurse. The circulating nurse is responsible for maintaining cleanliness, ensuring proper temperature, humidity, and lighting in the operating room. They coordinate activities, manage supplies, and ensure a safe environment for the surgical team. The scrub nurse assists the surgeon with instruments and supplies, not environmental conditions. The surgeon's main focus is on performing the surgery, not environmental management. The anesthesiologist is responsible for administering anesthesia and monitoring the patient's vital signs, not the operating room environment.
Question 4 of 5
Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
Correct Answer: D
Rationale: The correct answer is D: high calorie high protein. In COPD exacerbation, the body requires extra calories and protein for energy and muscle strength. High-calorie foods help combat weight loss and fatigue. High-protein foods aid in muscle repair and maintenance. Low-fat low-cholesterol (A) is not ideal as healthy fats are needed. Low-sodium (B) is not necessary unless there is concurrent heart failure. Bland soft diet (C) is not suitable as it does not provide enough calories and protein needed for COPD exacerbation.
Question 5 of 5
A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:
Correct Answer: C
Rationale: The correct answer is C: fluid volume deficit. In diabetes insipidus, there is an excessive amount of dilute urine excreted, leading to dehydration and fluid volume deficit. The posterior pituitary tumor causes a deficiency in antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys. As a result, the client experiences polyuria and polydipsia, leading to fluid volume deficit. Choices A, B, and D are incorrect because diabetes insipidus does not cause fluid volume excess, incontinence, or diarrhea. The key is to recognize the pathophysiology of diabetes insipidus and its impact on fluid balance.