ATI RN
Nursing Process NCLEX Questions Questions
Question 1 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: B
Rationale: The correct answer is B: Respiratory rate of 8 breaths/min. Morphine is an opioid that can cause respiratory depression as a side effect. A respiratory rate of 8 breaths/min indicates hypoventilation, which is a potential adverse effect of morphine. This is a critical finding that requires immediate intervention to prevent respiratory failure or arrest. A: Voiding of 350mL of concentrated urine in 8 hours is not directly related to morphine's adverse effects. Morphine can cause urinary retention, not increased voiding. C: Irregular heart rate of 82 beats/min is within normal range and not a typical adverse effect of morphine. Morphine can cause bradycardia or tachycardia, but not irregular heart rate specifically. D: Pupils constricted and equal is a common side effect of morphine due to its effect on the central nervous system. This finding does not suggest an adverse effect; it is an expected pharmac
Question 2 of 5
At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
Correct Answer: B
Rationale: The correct answer is B: Obesity. Obesity is a known risk factor for colon cancer as excess body fat, especially around the waist, can lead to inflammation and insulin resistance, increasing the likelihood of cancerous cell growth in the colon. Smoking (choice A) is more strongly associated with lung and other types of cancer, not specifically colon cancer. Heavy alcohol consumption (choice C) is linked to other types of cancer, such as liver and esophageal cancer, but not as strongly to colon cancer. Saccharin consumption (choice D) has not been definitively linked to an increased risk of colon cancer.
Question 3 of 5
or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
Correct Answer: A
Rationale: The correct answer is A because it reflects a measurable and client-centered outcome. Verbalizing feelings of anxiety indicates the client is acknowledging and addressing their emotions, which is essential in managing anxiety. Choice B is incorrect as it focuses on avoidance rather than expression of emotions. Choice C is incorrect as it doesn't specify the use of appropriate coping mechanisms. Choice D is incorrect as it suggests avoidance of seeking information, which may hinder the client's understanding and coping with the diagnosis.
Question 4 of 5
A very popular means of early detection of breast cancer is:
Correct Answer: D
Rationale: The correct answer is D: Breast self-examination. This is because regular breast self-examination allows individuals to become familiar with their own breast tissue and identify any changes or abnormalities early on. X-ray (choice A) and surgical (choice C) are not typically used as early detection methods for breast cancer. Choice B is also incorrect because while mammograms (X-rays) are an important screening tool, self-examination should not be replaced by it, as it is a proactive way for individuals to take charge of their own health.
Question 5 of 5
Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, “Why?” Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?
Correct Answer: C
Rationale: The correct answer is C: Pneumonia. Early postoperative ambulation helps prevent pneumonia by promoting lung expansion, increasing oxygenation, and preventing atelectasis. A: Increased peristalsis is unrelated to ambulation. B: Coughing is important for airway clearance but not directly related to ambulation. D: Wound healing is influenced by various factors, but ambulation primarily impacts respiratory function.