ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 9
A 61-year old female patient with diabetes is in the emergency department after stepping on a sharp onject while walking barefoot on the beach. The patient did not notice that the object pierced the skin unitl later that evening. What problem does she probably have?
Correct Answer: A
Rationale: The correct answer is A: neuropathy on her peripheral. In diabetes, peripheral neuropathy is common, causing loss of sensation in the feet, making it difficult to feel injuries like stepping on a sharp object. This can lead to delayed detection of wounds, increasing the risk of infections and complications. Nephropathy (B) refers to kidney damage, carpal tunnel syndrome (C) involves compression of the median nerve in the wrist, and macroangiopathy (D) refers to large blood vessel disease, which are not directly related to the scenario described.
Question 2 of 9
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should:
Correct Answer: B
Rationale: The correct answer is B: Wear gloves when providing mouth care. This is because standard precautions for AIDS include wearing gloves when in contact with bodily fluids, such as saliva during mouth care. Maintaining strict isolation (A) is not necessary as AIDS is not transmitted through casual contact. Keeping the client in a private room (C) is not required unless the client has an airborne infection. Wearing a gown when delivering food tray (D) is not necessary for standard precautions unless there is a risk of contamination with bodily fluids.
Question 3 of 9
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
Correct Answer: A
Rationale: The correct answer is A: Cancerous lumps. Breast self-examination aims to detect any abnormal changes in the breasts, including potential cancerous lumps. Detecting cancerous lumps early increases the chances of successful treatment and improved outcomes. Choices B, C, and D are incorrect because while changes from previous self-examinations, areas of thickness or fullness, and fibrocystic masses can be important to note, the primary goal of breast self-examination is to identify any signs of breast cancer, such as cancerous lumps.
Question 4 of 9
Which of the following client outcomes best describes the parameters for achieving the outcome?
Correct Answer: B
Rationale: The correct answer is B because it provides specific, measurable, achievable, relevant, and time-bound (SMART) parameters for achieving the outcome. It outlines the calorie intake, meal frequency, and start date, which allows for clear monitoring and evaluation of progress. Choice A is too vague and lacks specificity. Choice C focuses on wound care, not dietary goals. Choice D lacks specificity and a timeframe, making it difficult to measure success. In conclusion, choice B is the best option as it aligns with effective goal-setting principles.
Question 5 of 9
Marichu is admitted to the hospital because of hepatic failure and was prescribed with lactulose (Duphalac). The primary action of this drug is:
Correct Answer: B
Rationale: The correct answer is B: decrease resident intestinal flora. Lactulose is a synthetic sugar that is not absorbed in the intestine and is used to decrease ammonia levels in patients with hepatic encephalopathy by promoting the growth of beneficial gut bacteria that help metabolize ammonia. This action helps reduce the toxic effects of ammonia on the brain. A: prevent constipation - Lactulose may help with constipation, but its primary action in this scenario is to decrease resident intestinal flora. C: increase intestinal peristalsis - Lactulose does not directly increase peristalsis. D: prevent portal hypertension - Lactulose does not have a direct effect on preventing portal hypertension.
Question 6 of 9
Which of the ff symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?
Correct Answer: D
Rationale: The correct answer is D: Presence of laryngospasm. Laryngospasm is a serious complication of trauma to the upper airway that can lead to airway obstruction. Assessing for laryngospasm is crucial to ensure the client's airway remains patent. Pain when talking (A) is more related to vocal cord injury, increased nasal swelling (B) is a symptom of nasal trauma, and burning in the throat (C) may indicate pharyngeal injury, but laryngospasm (D) directly affects airway patency in upper airway trauma cases.
Question 7 of 9
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
Correct Answer: C
Rationale: Rationale: 1. Safety: Recording vital signs is crucial for patient safety. 2. Accountability: The nurse is ultimately responsible for ensuring vital signs are documented accurately. 3. Communication: It is essential for the nurse to communicate with the NAP to address the missed vital signs. 4. Corrective Action: Asking the NAP to record vital signs before administering medications ensures proper monitoring. 5. Patient-Centered Care: Prioritizing patient well-being by ensuring vital signs are up-to-date. Summary: A: Incorrect. Administering medications without vital sign assessment is unsafe. B: Incorrect. Reviewing vital signs upon return does not address the immediate need for accurate documentation. D: Incorrect. Omitting vital signs compromises patient safety and violates standard nursing practice.
Question 8 of 9
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
Correct Answer: A
Rationale: The correct answer is A: A-positive blood to an A-negative client. This is because in ABO blood typing, individuals with blood type A have anti-B antibodies in their plasma. Therefore, if A-positive blood (which contains the A antigen) is given to an A-negative client (who has anti-A antibodies), there is a high risk of an acute hemolytic reaction due to the antibodies attacking the transfused blood cells. Choices B, C, and D are incorrect because they do not involve a mismatch of ABO blood types that would lead to a significant risk of acute hemolytic reaction. In choice B, O-positive blood can be safely transfused to an A-positive client as O blood is considered the universal donor. In choice C, O-negative blood can be safely given to an O-positive client as O-negative blood is compatible with all blood types. In choice D, B-positive blood can be safely administered to an AB-positive client as the AB blood type can receive both
Question 9 of 9
The nurse would expect which of the following would be included in the plan of care/
Correct Answer: D
Rationale: Step 1: Monitoring electrolytes is essential to assess for potential imbalances due to the use of sodium bicarbonate, which can lead to hypokalemia and hypocalcemia. Step 2: Hypokalemia and hypocalcemia can result in serious complications such as cardiac arrhythmias and muscle weakness. Step 3: By monitoring electrolytes, the nurse can detect imbalances early and intervene promptly to prevent adverse effects. Summary: A: Drinking excessive water can lead to electrolyte imbalances and is not directly related to the use of sodium bicarbonate. B: Administering NaHCO3 IV is not within the nurse's scope of practice and should be done based on physician's orders. C: Continuing sodium bicarbonate for nausea may not be appropriate without monitoring electrolytes to prevent potential imbalances.