ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
Correct Answer: C
Rationale: Correct Answer: C - Tracheostomy set Rationale: 1. Immediate airway management: After thyroidectomy, there is a risk of airway compromise due to swelling or bleeding. Tracheostomy set ensures immediate access to secure the airway. 2. Emergency intervention: In case of respiratory distress or airway obstruction post-surgery, a tracheostomy set allows for prompt and effective intervention. 3. Patient safety and priority: Ensuring airway patency is crucial for the client's survival and takes precedence over other equipment. Summary of other choices: A: Indwelling urinary catheter kit - Not directly related to post-thyroidectomy care. B: Cardiac monitor - Important but secondary to airway management in this situation. D: Humidifier - Not essential for immediate post-thyroidectomy care.
Question 2 of 5
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
Correct Answer: D
Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus. Explanation for other choices: A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus. B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus. C: Above-normal urine osmolality level, below-normal
Question 3 of 5
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct: 1. Blood pressure is vital in this scenario due to prednisone discontinuation. 2. Abruptly stopping prednisone can lead to adrenal insufficiency. 3. Adrenal insufficiency can cause hypotension, a life-threatening condition. 4. Monitoring blood pressure can help detect and manage potential complications. Summary of other choices: A: Breath sounds – Important but not the priority in this specific situation. C: Capillary refill – Useful for assessing circulation but not urgent in this context. D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
Question 4 of 5
A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?
Correct Answer: D
Rationale: The correct evaluative measure is D: Lungs clear to auscultation following use of inhaler. This choice aligns with the expected outcome of having no secretions present in the lungs in 48 hours. By using an inhaler to clear the lungs, the nurse can assess if the expected outcome is being met. This measure directly evaluates the presence of secretions in the lungs, in line with the established goal. Incorrect Choices: A: No sputum or cough present in 4 days - This measure does not align with the expected outcome of having no secretions present in the lungs in 48 hours. B: Congestion throughout all lung fields in 2 days - This indicates a worsening condition and does not demonstrate progress towards the goal. C: Shallow, fast respirations 30 breaths per minute in 1 day - This measure is unrelated to the presence of secretions in the lungs and the goal of avoiding shortness of breath with activity.
Question 5 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.
Similar Questions
Join Our Community Today!
Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for ATI-RN and 3000+ practice questions to help you pass your ATI-RN exam.
Subscribe for Unlimited Access