ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?
Correct Answer: D
Rationale: The correct answer is D because a class V finding on a Pap test indicates severe dysplasia or carcinoma in situ, which requires further evaluation through a biopsy to confirm the presence of abnormal cells. This finding is not normal and necessitates immediate action for diagnosis and potential treatment. Choices A, B, and C are incorrect because they do not address the urgency and seriousness of a class V finding, which mandates prompt follow-up to rule out or confirm the presence of precancerous or cancerous cells.
Question 2 of 5
A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
Correct Answer: D
Rationale: The correct answer is D because a respiratory rate of 8 breaths/min indicates respiratory depression, a serious adverse effect of morphine. Morphine is a central nervous system depressant that can suppress the respiratory drive, leading to hypoventilation and potentially respiratory failure. This is a life-threatening complication that requires immediate intervention. A: Voiding of 350mL of concentrated urine is not typically associated with morphine use. B: An irregular heart rate of 82 beats/min is within a normal range and not a common adverse effect of morphine. C: Pupils constricted and equal is a common side effect of morphine due to its action on the central nervous system, not necessarily indicating an adverse effect.
Question 3 of 5
A client has malignant lymphoma. As part of her chemotherapy, the physician prescribes chlorambucil (Leukeran), 10mg by mouth daily. When caring for the client, the nurse teaches her about adverse reactions to chlorambucil, such as alopecia. How soon after the first administration of chorambucil might this reaction occur?
Correct Answer: B
Rationale: The correct answer is B: 2 to 3 weeks. Alopecia (hair loss) is a common adverse reaction of chlorambucil, typically occurring 2 to 3 weeks after the first administration. This is due to the drug's effect on rapidly dividing cells, including hair follicles. Immediate onset (Choice A) is unlikely as it takes time for the drug to affect hair growth. One week (Choice C) is too soon for alopecia to manifest. One month (Choice D) is too long as alopecia usually occurs earlier. Therefore, the correct window for alopecia onset after chlorambucil administration is 2 to 3 weeks.
Question 4 of 5
In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:
Correct Answer: C
Rationale: The correct answer is C: Uterine body. The rationale is that the most common site of cancer for females is uterine body, specifically endometrial cancer. This is due to the high prevalence of hormonal imbalances and estrogen exposure, which are risk factors for this type of cancer. The other choices, A: Uterine cervix, B: Vagina, and D: Fallopian tube, are less common sites of cancer in females compared to the uterine body. Understanding the prevalence and risk factors associated with each site of cancer is crucial for nurses to educate clients effectively.
Question 5 of 5
Which of the ff adverse reactions may occur when a client is taking danazol (Danocrine) for fibrocystic breast disease?
Correct Answer: B
Rationale: The correct answer is B: Amenorrhea. Danazol is a synthetic steroid used to treat fibrocystic breast disease by suppressing ovulation and hormonal fluctuations. This leads to a decrease in menstrual bleeding, resulting in amenorrhea. Nausea and confusion are not common adverse reactions of danazol. Hypotension is also not associated with danazol use. In summary, amenorrhea is the expected side effect due to the drug's mechanism of action, making it the correct choice compared to the other options.