ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 5
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
Correct Answer: B
Rationale: The correct answer is B: Reduced sneezing. Decongestants work by constricting blood vessels in the nasal passages, reducing swelling and congestion, which in turn can lead to a decrease in sneezing. Increased salivation (choice A) is not a typical effect of decongestants. Increased tearing (choice C) is more commonly associated with allergies or irritants. Headache (choice D) can be a side effect of decongestants due to their impact on blood vessels, but it does not necessarily indicate effectiveness in treating allergic rhinitis.
Question 2 of 5
Through which of the following does lymph return to the blood?
Correct Answer: D
Rationale: The correct answer is D: Subclavian veins. Lymph returns to the blood through the subclavian veins because they receive lymphatic drainage from the thoracic duct and right lymphatic duct. Lymphatic vessels merge into lymphatic ducts, which empty into the subclavian veins, allowing lymph to re-enter the bloodstream. The carotid arteries (A) carry oxygen-rich blood to the brain, the aorta (C) is the main artery of the body carrying oxygenated blood from the heart, and the inferior vena cava (B) returns deoxygenated blood from the lower body to the heart. Therefore, choices A, B, and C are incorrect as they are not involved in the return of lymph to the blood.
Question 3 of 5
A patient with a history of haemophilia A arrives in the emergency department complaining of a “funny feeling” in his elbow. The patient states that he thinks he is bleeding into the joint. Which response by the nurse is correct?
Correct Answer: B
Rationale: The correct response is B: Notify the physician immediately and expect an order for factor VIII. In a patient with hemophilia A, which is a deficiency of clotting factor VIII, bleeding into a joint can lead to serious complications. The nurse should notify the physician promptly because the patient may need factor VIII replacement therapy to stop the bleeding and prevent further damage. This is a medical emergency requiring timely intervention. Choices A, C, and D are incorrect: A: Palpating the elbow could exacerbate the bleeding and cause further damage. C: Ordering an x-ray would delay the crucial factor VIII replacement therapy needed to manage the bleeding. D: Applying heat can increase blood flow to the joint, worsening the bleeding.
Question 4 of 5
A client who is HIV positive should have the mouth examined for which oral problem common associated with AIDS?
Correct Answer: B
Rationale: The correct answer is B: Creamy white patches. These patches are indicative of oral thrush, a common fungal infection seen in individuals with weakened immune systems like those with AIDS. This infection is caused by Candida albicans. It presents as white patches on the tongue, inner cheeks, or roof of the mouth. Halitosis (A) is bad breath, not specific to AIDS. Carious teeth (C) refers to cavities, not directly related to AIDS. Swollen lips (D) can be a symptom of various oral conditions, but not specific to AIDS. In summary, creamy white patches are a characteristic oral problem associated with AIDS due to opportunistic infections like oral thrush.
Question 5 of 5
Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
Correct Answer: D
Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.