ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100mcg IM daily. Which substance influences Vitamin B12 absorption?
Correct Answer: A
Rationale: Rationale: Intrinsic factor is a glycoprotein produced by the stomach that is essential for the absorption of vitamin B12 in the ileum. Without intrinsic factor, vitamin B12 absorption is impaired, leading to megaloblastic anemia. Histamine and hydrochloric acid are not directly involved in vitamin B12 absorption. Liver enzymes are not implicated in the absorption process. Therefore, the correct answer is A.
Question 2 of 5
Which of the ff. interventions can help minimize complications related to Hypercalcemia?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Hypercalcemia can lead to dehydration due to increased urine output. 2. Encouraging 3 to 4 L of fluid daily helps prevent dehydration and promote renal excretion of excess calcium. 3. Adequate hydration reduces the risk of kidney stones and other complications associated with hypercalcemia. Summary of why other choices are incorrect: - Choice B (bed rest) does not directly address hypercalcemia complications. - Choice C (cough and deep breathe) is unrelated to managing hypercalcemia. - Choice D (apply heat to painful areas) does not address the underlying cause of hypercalcemia or its complications.
Question 3 of 5
An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
Correct Answer: A
Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.
Question 4 of 5
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Lymphangitis is an inflammation of lymphatic vessels. 2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection. 3. Nurse should notify the physician for further evaluation and treatment. 4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification. 5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification. 6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.
Question 5 of 5
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
Correct Answer: B
Rationale: The correct answer is B: "Keep the stoma dry." Keeping the stoma dry helps prevent infection and skin irritation. Moisture can lead to fungal growth and skin breakdown. Option A is incorrect because keeping the stoma uncovered can increase the risk of contamination and infection. Option C is incorrect as self-care promotes independence and allows the client to become familiar with the procedure. Option D is incorrect as moisture can lead to skin issues.