ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
Correct Answer: B
Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications. A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances. C: Hyperchloremia is not a common concern in this scenario based on the given lab values. D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.
Question 2 of 5
Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The nurse explains that:
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. Paraplegia is a condition where both lower extremities are paralyzed. 2. The prefix "para-" means alongside or beside, indicating that both legs are affected. 3. The nurse would explain to the family that Mr. Gubatan has paralysis in his lower extremities only. 4. This aligns with the medical definition of paraplegia. Summary of Incorrect Choices: A. Upper extremities being paralyzed is not indicative of paraplegia, as paraplegia specifically refers to lower extremity paralysis. B. Both lower and upper extremities being paralyzed is suggestive of quadriplegia, not paraplegia. D. One side of the body being paralyzed describes hemiplegia, not paraplegia.
Question 3 of 5
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.
Question 4 of 5
Usually, how does the patient behave after his seizure has subsided?
Correct Answer: B
Rationale: The correct answer is B: Sleeps for a period of time. After a seizure, the brain and body experience fatigue and exhaustion. It is common for the patient to feel drowsy and require rest to recover. This post-ictal state is characterized by sleepiness and confusion. The other choices are incorrect because typically, after a seizure, the patient is not most comfortable walking and moving about (A), does not become restless and agitated (C), and may not immediately express thirst and hunger (D). It is important to ensure the patient is in a safe environment and allow them to rest after a seizure episode.
Question 5 of 5
Patients with Guillain-Barre Syndrome should be closely monitored. Which of the ff. parameters is most important to be checked regularly for acute complications?
Correct Answer: C
Rationale: The correct answer is C: ABG. Monitoring ABG in Guillain-Barre Syndrome patients is crucial as they are at risk for respiratory complications like respiratory failure due to muscle weakness. ABG provides information on oxygenation, ventilation, and acid-base balance. Regular monitoring helps detect early signs of respiratory distress and guide appropriate interventions. A: BUN and creatinine are important for assessing renal function, but they do not directly relate to acute complications in Guillain-Barre Syndrome. B: Hgb and Hct are markers for anemia, which is not a common acute complication in Guillain-Barre Syndrome. D: Serum potassium levels are important, but ABG monitoring takes precedence in patients with Guillain-Barre Syndrome due to the risk of respiratory issues.