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
Autoimmunity is defined as a phenomenon involving which of the following?
Correct Answer: D
Rationale: Autoimmunity is when the immune system mistakenly attacks the body's own cells. Choice D is correct because it reflects this key feature - the inability to differentiate self from nonself. This leads to the immune system targeting healthy tissues. Choices A, B, and C are incorrect as they do not accurately describe autoimmunity. Choice A refers to endotoxins destroying B cells, which is not the definition of autoimmunity. Choice B mentions overproduction of reagin antibody, which is not related to autoimmunity. Choice C is incorrect as autoimmunity does not involve depression of the immune response but rather an inappropriate immune response.
Question 3 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 4 of 9
Which food is recommended for the patient who must increase intake of potassium?
Correct Answer: B
Rationale: The correct answer is B: Potato. Potatoes are high in potassium, which is essential for various bodily functions. Potatoes can help increase potassium intake in patients who require it. Bread, eggs, and cereal are not as rich in potassium as potatoes. Increasing intake of these foods won't provide the necessary boost in potassium levels needed for the patient.
Question 5 of 9
A male client age 78, complaints of dizziness, especially when he stands up after sleeping or sitting. The client also informs the nurse that he periodically experiences nosebleeds and blurred vision. Which of the ff conditions should the nurse assess for the client?
Correct Answer: A
Rationale: The correct answer is A: Postural hypotension. This condition is characterized by a drop in blood pressure upon standing, leading to dizziness. The client's symptoms of dizziness upon standing, along with nosebleeds and blurred vision, are indicative of low blood pressure. Postural hypertension (B) is not a recognized medical condition; White coat hypertension (C) refers to elevated blood pressure readings in a medical setting due to anxiety; White coat hypotension (D) is not a recognized medical condition.
Question 6 of 9
Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:
Correct Answer: C
Rationale: The correct answer is C: To rule out cholinergic crisis Neostigmine. Edrophonium HCL is a short-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis, as both conditions present similarly with muscle weakness. Administering edrophonium HCL will help determine if the patient's worsening weakness is due to excessive cholinergic stimulation from neostigmine (cholinergic crisis) or inadequate acetylcholine at the neuromuscular junction (myasthenic crisis). This step is crucial for proper management, as treating cholinergic crisis with more cholinesterase inhibitors like neostigmine can worsen symptoms. Incorrect choices: A: For its synergistic effect - Edrophonium HCL does not have a synergistic effect with neostigmine. B: Because of the client's resistance to - Resistance to neostigmine is not a reason to administer edrophonium H
Question 7 of 9
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
Correct Answer: D
Rationale: The correct answer is D: Strawberries. Strawberries are a common allergen due to their high allergenic potential. When taking a dietary history, it is important to identify potential allergens to prevent adverse reactions. Oranges, carrots, and bread are not as commonly associated with allergies compared to strawberries. Identifying common allergens helps in providing safe and appropriate dietary recommendations for clients.
Question 8 of 9
A client has been diagnosed with type 1 diabetes mellitus. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?
Correct Answer: A
Rationale: The correct answer is A: “You’ll need more insulin when you exercise or increase your food intake.” In type 1 diabetes, exercise and increased food intake can lead to increased glucose levels, requiring more insulin to maintain blood sugar control. Increasing physical activity can enhance insulin sensitivity, necessitating adjustments in insulin dosage. Choices B, C, and D are incorrect as they do not align with the physiological response in type 1 diabetes. B suggests needing less insulin when exercising, which is inaccurate as physical activity can lower blood sugar levels. C implies needing less insulin with increased food intake, which is incorrect as more food can lead to higher glucose levels. D suggests needing more insulin when decreasing food intake, which is not necessarily true as lower food intake can result in lower glucose levels.
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 gather objective data directly from the patient's body, such as vital signs, skin condition, and overall health status. It provides a comprehensive overview of the patient's current health status and helps in establishing a baseline for further assessments and interventions. Reviewing literature (A) is important for evidence-based practice but does not directly establish a patient's database. Checking orders for tests (B) is essential but does not provide a holistic view of the patient. Ordering medications (D) is a treatment intervention and not a data collection method.