ATI RN
Nursing Process Test Questions Questions
Question 1 of 9
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
Correct Answer: D
Rationale: The correct answer is D, Leucovorin. Leucovorin is administered with methotrexate to protect normal cells from methotrexate toxicity by acting as a "rescue" agent. Methotrexate inhibits dihydrofolate reductase, leading to decreased levels of tetrahydrofolate needed for DNA synthesis. Leucovorin bypasses this step by directly providing the reduced form of folic acid, thus preventing toxicity in normal cells. Probenecid (choice A) is not used to protect normal cells during methotrexate therapy. Cytarabine (choice B) and Thioguanine (choice C) are not rescue agents for methotrexate toxicity.
Question 2 of 9
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
Correct Answer: D
Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.
Question 3 of 9
A client with neuromuscular disorder is receiving intensive nursing care. The client is likely to face the risk for impaired skin integrity. Which of the ff must the nurse ensure to prevent skin breakdown in the client?
Correct Answer: B
Rationale: The correct answer is B: Use pressure relieving devices when the client is in bed. This is because pressure ulcers are a common risk for individuals with neuromuscular disorders due to immobility. Pressure relieving devices such as special mattresses or cushions help redistribute pressure and prevent skin breakdown. Incorrect choices: A: Preventing strenuous exercises is not directly related to preventing skin breakdown in this case. C: Placing the client in Fowler's position may be beneficial for respiratory issues but does not directly address skin integrity. D: Avoiding daily baths with soaps may lead to poor hygiene and does not specifically address the risk of skin breakdown.
Question 4 of 9
The physician prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide?
Correct Answer: A
Rationale: The correct answer is A: “Be sure to take glipizide 30 minutes before meals.” This instruction is correct because glipizide is an oral antidiabetic agent that works best when taken before meals to help control blood glucose levels. Taking it before meals allows the medication to coincide with the body's natural insulin response to food intake, thereby improving its effectiveness. Choice B is incorrect because glipizide does not typically cause low serum sodium levels, so there is no need for monthly sodium level checks. Choice C is incorrect because it is essential for the client to continue monitoring their blood glucose levels even after starting glipizide to ensure the medication is working effectively. Choice D is incorrect because taking glipizide after a meal will not optimize its effectiveness in controlling blood glucose levels.
Question 5 of 9
Which of the ff. statements does the nurse understand is true concerning air conduction of sound in the ear?
Correct Answer: B
Rationale: The correct answer is B because air conduction is less efficient than bone conduction due to the sound waves traveling through the air in the ear canal, which can be hindered by factors like blockages or obstructions. This results in a weaker and less clear sound transmission compared to bone conduction, where sound waves are transmitted directly through the bones of the skull, bypassing any potential obstructions in the ear canal. Incorrect choices: A: This statement is incorrect as air conduction of sound in the ear is not caused by the vibration of bones in the skull. C: This statement is incorrect as air conduction is typically heard for a shorter duration than bone conduction. D: This statement is incorrect as air conduction of sound in the ear is not caused by the transmission of heat through the air, but rather by sound waves traveling through the ear canal.
Question 6 of 9
The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
Correct Answer: C
Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting the assessment by examining a specific aspect (surgical dressing with drainage) and will likely proceed to gather more detailed information based on the initial findings. This approach involves moving from a broad overview to specific details, which is essential in assessing postoperative patients for complications. A: Gordon’s Functional Health Patterns is a comprehensive assessment framework that covers various aspects of an individual's health, not specifically focusing on the progression from general to specific assessments in this situation. B: Activity-exercise pattern assessment focuses on the patient's activity levels and exercise routines, which is not the primary focus of the scenario described. D: Problem-oriented assessment is a method that involves identifying and addressing specific health issues or concerns, which is not the primary aim of the assessment approach used by the nurse in this scenario.
Question 7 of 9
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
Correct Answer: B
Rationale: The correct answer is B: Hives or rashes. In autoimmune disorders, the immune system mistakenly attacks the body's own tissues, leading to various symptoms. Hives or rashes are common manifestations of autoimmune disorders due to the immune response affecting the skin. Other choices are incorrect because hypotension is not typically associated with autoimmune disorders, localized inflammation may be present but is not specific to autoimmune disorders, and cramping and vomiting are not primary signs of autoimmune disorders.
Question 8 of 9
During the physical examination of a client for a possible neurologic disorder, how can the nurse examine the client for stiffness and rigidity of the neck?
Correct Answer: B
Rationale: The correct answer is B. To examine stiffness and rigidity of the neck, the nurse should move the client's head and chin toward the chest. This maneuver assesses for resistance and limitation in neck flexion, which can indicate stiffness and rigidity commonly seen in neurologic disorders like meningitis or cervical dystonia. A: Positioning the client flat on the bed for hours does not specifically target neck stiffness and rigidity. C: Asking the client to bend and pick up objects assesses motor function, not neck stiffness. D: Introducing a painful stimulus is not a standard or appropriate method for examining neck stiffness and rigidity.
Question 9 of 9
Which of the ff nursing interventions ensure that a client with Hodgkin’s disease remains free of infection? Choose all that apply
Correct Answer: C
Rationale: Rationale: C: Practice conscientious hand washing is correct as it helps prevent the spread of infection. Proper hand hygiene is essential in reducing the risk of infection transmission to the client with Hodgkin's disease. A: Apply ice to the skin for brief periods is incorrect as it does not directly relate to preventing infection in the client. B: Provide cool sponge baths is incorrect as it mainly addresses comfort and hygiene but does not specifically target infection prevention. D: Use cotton gloves Restrict visitors or personnel with infections from contact with the client is incorrect because while using gloves can help prevent the spread of infection, restricting visitors with infections is not under the direct control of the nurse. Summary: Practicing conscientious hand washing is crucial in preventing infection in a client with Hodgkin's disease, while the other choices do not directly address infection control in this context.