ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 9
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (sub-arachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?
Correct Answer: B
Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage. 1. Positioning is crucial to prevent CSF leakage as the spinal block is administered into the sub-arachnoid space where CSF is present. 2. Incorrect Answers: A: Positioning is not related to preventing confusion in this context. C: Seizures are not typically associated with spinal block anesthesia. D: Cardiac arrhythmias are not directly impacted by the client's positioning for a spinal block.
Question 2 of 9
Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.
Question 3 of 9
A patient asks how to avoid lung cancer. The following are risk factors, except:
Correct Answer: B
Rationale: Step 1: Crowded living conditions do not directly increase the risk of lung cancer. Step 2: Passive smoke (choice A) and air pollution (choice C) contain carcinogens linked to lung cancer. Step 3: Diet low in fruits and vegetables (choice D) may lead to poor immune function, potentially impacting cancer risk. Step 4: In summary, crowded living conditions do not contribute to lung cancer risk compared to the other choices.
Question 4 of 9
The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client’s health status. Which of the following would the nurse identify as a subjective cue?
Correct Answer: A
Rationale: The correct answer is A because sharp pain is a subjective cue as it is based on the client's personal experience and perception. The client is the only one who can report the presence and intensity of pain. B: Small bloody drainage is an objective cue that can be observed and measured by the nurse. C: Temperature of 102 degrees F is an objective cue that can be measured using a thermometer. D: Pulse rate of 90 beats per minute is an objective cue that can be measured using a pulse oximeter. In summary, subjective cues are based on the client's feelings and perceptions, while objective cues are observable and measurable by the healthcare provider.
Question 5 of 9
Which method of data collection will the nurse use to establish a patient’s database?
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather patient data through observation, palpation, percussion, and auscultation. It helps in assessing the patient's overall health status, identifying any abnormalities, and establishing a baseline for further care. Reviewing literature (A) helps in evidence-based practice but does not directly collect patient data. Checking orders for tests (B) and ordering medications (D) involve actions based on data collected rather than collecting the data itself.
Question 6 of 9
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?
Correct Answer: A
Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.
Question 7 of 9
The nurse is teaching a class about breast self-examinations. A client asks if the she should have an annual mammogram. According to the American Cancer Society, how should the nurse respond?
Correct Answer: B
Rationale: The correct answer is B: All women over age 40 should have an annual mammogram. The American Cancer Society recommends annual mammograms starting at age 40 for women with an average risk of breast cancer. This is based on evidence showing that regular mammograms starting at age 40 help in early detection and improve outcomes. Choice A is incorrect because the recommended age is 40, not 30. Choice C is incorrect as it focuses only on family history, while screening guidelines are based on overall risk factors. Choice D is incorrect because feeling at risk alone is not a sufficient indication for annual mammograms without considering other risk factors.
Question 8 of 9
The nurse will monitor J.E. for the following signs and symptoms:
Correct Answer: A
Rationale: The correct answer is A. 1. Change in level of consciousness is crucial in assessing neurological status. 2. Tachypnea indicates possible respiratory distress or oxygenation issues. 3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion. 4. Petechiae can be a sign of bleeding disorders or sepsis. Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms. Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E. Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.
Question 9 of 9
Which method of data collection will the nurse use to establish a patient’s database?
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to collect objective data directly from the patient, which is crucial in establishing a comprehensive patient database. By assessing the patient's physical condition, the nurse can gather vital information such as vital signs, overall health status, and potential areas of concern. Reviewing literature (A) and checking orders for tests (B) may provide additional insights but are not direct data collection methods. Ordering medications (D) is a treatment intervention, not a data collection method.