ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 5
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?
Correct Answer: B
Rationale: The correct answer is B because red, open sores on the oral mucosa are a common sign of stomatitis, which can be caused by chemotherapy. Stomatitis is characterized by inflammation and ulceration of the mouth lining. The other choices are incorrect because: A: White, cottage cheese-like patches are indicative of oral thrush, a fungal infection. C: Rust-colored sputum may indicate a respiratory condition or infection, not stomatitis. D: Yellow tooth discoloration is not typically associated with stomatitis, but can be caused by various factors such as poor oral hygiene or certain foods.
Question 2 of 5
. Which of the following laboratory test results would the nurse expect to find in a client diagnosed with Hashimoto’s thyroiditis?
Correct Answer: C
Rationale: Rationale for correct answer C: In Hashimoto's thyroiditis, an autoimmune disorder causing hypothyroidism, we expect to see normal to elevated TSH levels due to the pituitary gland stimulating the thyroid to produce more hormones. T4 and T3 levels may be within normal range or slightly decreased. Choice C reflects this pattern with T4 at 22 ug/dl, T3 at 200 ng/dl, and TSH at 0.1 uIU/ml. Summary of why other choices are incorrect: - Choice A: T4 and T3 levels are higher than expected in Hashimoto's thyroiditis, and TSH should be elevated, not stated as normal. - Choice B: An undetectable TSH level is typically seen in hyperthyroidism, not hypothyroidism like Hashimoto's. - Choice D: T4 and T3 levels are significantly lower than expected, and TSH is much higher than typically seen in Hashimoto's
Question 3 of 5
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
Correct Answer: A
Rationale: The correct answer is A: Assessment. The nurse made an error in the assessment phase by not communicating the patient's condition promptly. Assessment involves collecting data and recognizing changes in the patient's condition. By not informing the nurse about feeling dizzy and light-headed, the nurse missed crucial information that could have indicated a deteriorating condition. The other choices are incorrect because: B: Diagnosis comes after assessment and involves analyzing data to identify the patient's problems. C: Implementation is the phase where nursing interventions are carried out based on the diagnosis. D: Evaluation is the final phase where the nurse assesses the effectiveness of interventions and outcomes.
Question 4 of 5
A patient is being given penicillin via IV piggyback and develops an anaphylactic reaction. Which of the following should be the nurse’s first action?
Correct Answer: D
Rationale: The correct answer is D: Turn off the antibiotic. This should be the nurse's first action because in an anaphylactic reaction, stopping the administration of the causative agent is crucial to prevent further harm. Continuing the antibiotic (Choice B) can worsen the reaction. Calling the doctor (Choice A) may cause a delay in the immediate intervention needed. Calling for help (Choice C) is important but turning off the antibiotic takes precedence to stop the allergen.
Question 5 of 5
A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct: 1. Safety: Morbidly obese patients are at higher risk of falls during transfers. 2. Assistance: Having two other personnel ensures safe transfer. 3. Weight distribution: Distributing the patient's weight among multiple helpers reduces strain. 4. Proper body mechanics: Allows for proper positioning and technique while assisting. Summary of why other choices are incorrect: B. Medication doesn't address the safety concern of transferring a morbidly obese patient. C. Reviewing activity orders is not the immediate action needed for the patient's first bathroom transfer. D. Offering a walker may not provide sufficient support for a morbidly obese patient during the transfer.
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