ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
Correct Answer: D
Rationale: The correct answer is D: Restricting fluids. In SIADH, there is an excess of antidiuretic hormone leading to water retention and dilutional hyponatremia. Restricting fluids helps to prevent further water retention and hyponatremia. Rapid IV fluid infusion (A) worsens the condition by further diluting sodium levels. Administering glucose-containing IV (B) is not directly related to treating SIADH. Encouraging increased oral intake (C) can exacerbate the condition by increasing fluid intake.
Question 2 of 5
A 57-year old patient had a right lower lobectomy. The nurse should initiate this action when the patient arrives from the Post Anesthesia Care Unit:
Correct Answer: A
Rationale: The correct answer is A: immediately administer pain relief. After a lobectomy, the patient may experience significant pain due to the surgical incision and chest tube insertion. Providing prompt pain relief is crucial to ensure the patient's comfort and prevent complications such as shallow breathing or limited mobility. This action will also aid in the patient's early recovery and promote better outcomes. Choice B (keep patient in semi-fowler's position) is not the priority upon arrival from the Post Anesthesia Care Unit as pain management takes precedence. Choice C (turn client every hour) is important for preventing complications but is not the immediate action required upon arrival. Choice D (notify the family to report patient's condition) is important but not as urgent as providing pain relief to the patient.
Question 3 of 5
An elderly patient, Mr. Cruz is being cared for by nurse Bennie because of pulmonary embolism. Nurse Bennie would anticipate an order for immediate administration of:
Correct Answer: B
Rationale: The correct answer is B: heparin. Heparin is an anticoagulant used for immediate treatment of pulmonary embolism to prevent further clot formation. It acts quickly by inhibiting clotting factors. Warfarin (A) is used for long-term anticoagulation but has a slower onset. Dexamethasone (C) is a corticosteroid used for inflammation, not thrombosis. Protamine sulfate (D) is used to reverse the effects of heparin but is not indicated for initial treatment.
Question 4 of 5
A patient had a lumbar injury. Which neurological test by the nurse would be affected?
Correct Answer: C
Rationale: The correct answer is C: Romberg’s test. Romberg’s test assesses a patient's ability to maintain balance with eyes closed, relying on proprioception from the lower limbs. A lumbar injury can affect proprioception, leading to impaired balance. Rhine’s test evaluates auditory function, not affected by a lumbar injury. Pupillary reaction assesses cranial nerve function, unrelated to a lumbar injury. The patellar reflex is a deep tendon reflex, primarily involving the spinal cord segments L2-L4, not directly affected by a lumbar injury.
Question 5 of 5
Mr. Galino is diagnosed to have Raynaud’s disease. Nurse Oliver gives instructions to the client to stop smoking because it causes:
Correct Answer: B
Rationale: The correct answer is B: vasoconstriction, vasospasms. 1. Raynaud's disease involves exaggerated vasoconstriction and vasospasms of blood vessels in response to cold or stress. 2. Smoking aggravates vasoconstriction and vasospasms by constricting blood vessels further. 3. This can worsen symptoms for individuals with Raynaud's disease. 4. Choices A, C, and D do not directly relate to the mechanism of Raynaud's disease and smoking.