ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 9
A client asks nurse Carlos the rationale for giving multi-drug treatment for tuberculosis. Which is an appropriate response?
Correct Answer: D
Rationale: The correct answer is D because using multiple drugs for tuberculosis reduces the development of resistant strains of the bacteria. When multiple drugs are used simultaneously, it decreases the likelihood of the bacteria developing resistance to any single drug. This approach helps to ensure that the treatment remains effective over time. Explanation for other choices: A: While using multiple drugs may allow for reduced dosages, the primary rationale is not solely to administer lower levels of drugs. B: Although using multiple drugs may help in managing side effects, the primary rationale is to prevent the development of resistant strains. C: While multiple drugs may have a synergistic effect, the main purpose is to prevent resistance rather than potentiate the action of individual drugs.
Question 2 of 9
A client has the following blood lab values: platelets 50,000/ul, RBC’s 3.5 (X 106), hemoglobin 10 g/dl, hematocrit 30 percent, WBCs 10,000/ul. Which nursing instruction should be included in the teaching plan?
Correct Answer: A
Rationale: The correct answer is A: Bleeding precautions. With low platelets (50,000/ul), the client is at risk for bleeding. Platelets help with blood clotting, so precautions to prevent bleeding are essential. This includes avoiding activities that can cause injury, using a soft toothbrush, and reporting any signs of bleeding. Summary: B: Isolation to prevent infection - This is not related to the client's lab values. C: Seizure precautions - Not relevant to the client's lab values. D: Control of pain with analgesics - Pain management is not the priority given the client's lab values indicating a risk of bleeding.
Question 3 of 9
A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?
Correct Answer: C
Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis. A: Hyperventilation would lead to respiratory alkalosis, not acidosis. B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis. D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis. In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.
Question 4 of 9
Which of the ff statements justifies the administration of the prescribed anticonvulsant phenytoin to a client before the intracranial surgery?
Correct Answer: A
Rationale: Step 1: Phenytoin is an anticonvulsant used to prevent seizures. Step 2: Anticonvulsants are often given before surgery to reduce the risk of seizures during and after the procedure. Step 3: In the context of intracranial surgery, controlling seizures is crucial to prevent complications like increased intracranial pressure. Step 4: Therefore, administering phenytoin before surgery helps in reducing the risk of seizures before and after the procedure. Summary: - Option B (avoid intraoperative complications) is too broad and doesn't directly relate to the use of phenytoin. - Option C (reduce cerebral edema) is not the primary indication for phenytoin in this scenario. - Option D (prevent postoperative vomiting) is not a common reason for administering phenytoin before intracranial surgery.
Question 5 of 9
A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:
Correct Answer: D
Rationale: The correct answer is D: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. It is a more reliable indicator compared to other options. A: Urine glucose level only shows current glucose levels and is not a reliable indicator of long-term control. B: Serum fructosamine level reflects blood glucose control over the past 2-3 weeks, not the 3-month period the client has been making efforts. C: Fasting blood glucose level gives a snapshot of the current glucose level, not long-term control like glycosylated hemoglobin does.
Question 6 of 9
After the surgical incision has been clised and the anesthesia has wear-off, the patient is extubated and transferred to the postanesthesia care unit (PACU). Who is responsible for transferring the patient?
Correct Answer: D
Rationale: The correct answer is D: anesthesiologist. The anesthesiologist is responsible for transferring the patient to the PACU as they are in charge of the patient's anesthesia management throughout the surgery. They are trained to assess the patient's condition post-surgery, manage any immediate postoperative complications, and ensure a smooth transition to the PACU staff for continued care. The circulating nurse (A) is responsible for managing the operating room environment, the scrub nurse (B) assists the surgeon during the surgery by passing instruments, and the surgeon (C) performs the surgical procedure but does not typically transfer the patient to the PACU.
Question 7 of 9
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
Correct Answer: D
Rationale: The correct answer is D because it involves a comprehensive approach to addressing the patient's concern. By asking the patient about usual sleep patterns and the onset of having difficulty resting, the nurse can gather important information to assess the potential correlation between the leg cast and restless sleep. This approach demonstrates active listening and shows concern for the patient's well-being. Option A is incorrect because it dismisses the patient's concern and does not address the underlying issue. Option B is also incorrect as it focuses solely on documentation without actively addressing the patient's concern. Option C is not the best choice as it delays addressing the patient's immediate need for help with sleeping, which may impact their overall recovery.
Question 8 of 9
Which nursing intervention is most appropriate for a client with multiple myeloma?
Correct Answer: D
Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, bone lesions are common due to bone destruction by abnormal plasma cells. Preventing bone injury is crucial to avoid fractures and bone pain. This can be achieved through careful handling, fall prevention, and avoiding activities that may increase the risk of bone damage. Monitoring respiratory status (A) is not the priority in multiple myeloma. Balancing rest and activity (B) is important but not as critical as preventing bone injury. Restricting fluid intake (C) is not typically necessary unless there are specific indications like renal issues.
Question 9 of 9
Which blood product replaces missing clotting factors in the patient who has a bleeding disorder?
Correct Answer: D
Rationale: The correct answer is D: Cryoprecipitate. Cryoprecipitate contains high levels of clotting factors such as fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor, making it the ideal choice to replace missing clotting factors in patients with bleeding disorders. Platelets (A) help with clot formation but do not contain clotting factors. Albumin (B) is a protein used for volume replacement, not clotting factor replacement. Packed RBC (C) is used to increase oxygen-carrying capacity in anemic patients, not for clotting factor replacement.