ATI RN
Nursing Process Test 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. Rationale: During a spinal block, the anesthesiologist injects anesthesia into the subarachnoid space, which contains CSF. Proper positioning ensures that the anesthesia stays in place and prevents leakage of CSF, which could lead to complications such as post-dural puncture headache. Incorrect choices: A: To prevent confusion - Irrelevant to the procedure. C: To prevent seizures leakage - Seizures are not a concern with spinal blocks. D: To prevent cardiac arrhythmias - Cardiac arrhythmias are not directly related to spinal blocks.
Question 2 of 9
Postural Hypotension is A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
Correct Answer: A
Rationale: The correct answer is A because postural hypotension is defined as a drop in systolic blood pressure of greater than 20 mmHg or a drop in diastolic blood pressure of greater than 10 mmHg within 3 minutes of standing from a sitting or supine position. Therefore, a drop in systolic pressure greater than 10 mmHg when changing from lying to sitting is indicative of postural hypotension. Choice B is incorrect as postural hypotension is primarily defined by changes in systolic blood pressure, not diastolic. Choice C is incorrect because a drop in diastolic pressure greater than 10 mmHg is not the defining characteristic of postural hypotension. Choice D is not provided.
Question 3 of 9
The most likely cause of her chief complaint this morning is
Correct Answer: D
Rationale: The correct answer is D because polyuria is a common complication of hypophysectomy, the surgical removal of the pituitary gland. The pituitary gland plays a crucial role in regulating water balance in the body, and its removal can lead to excessive urine production. Choices A, B, and C are incorrect because a decrease in stress does not typically cause polyuria, diabetes mellitus is not an immediate complication of surgery, and polyuria is not an expected result of pituitary gland removal.
Question 4 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 5 of 9
Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
Correct Answer: C
Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.
Question 6 of 9
Why should the nurse closely monitor older adults when they are receiving IV therapy? Choose all that apply
Correct Answer: E
Rationale: The correct answer is not provided in the choices. However, if I were to choose from the given options, the most appropriate would be C: "Because they are prone to reduced renal efficiency." This is important because older adults may have decreased kidney function, leading to potential complications with IV therapy. Option A is incorrect as defense mechanisms are not directly related to monitoring IV therapy. Option B is incorrect as fluid overload is a general concern with IV therapy regardless of age. Option D is irrelevant to the need for monitoring IV therapy in older adults.
Question 7 of 9
Which of the following is the most critical intervention needed for a client with myxedema coma?
Correct Answer: A
Rationale: The correct answer is A: Administering an oral dose of levothyroxine (Synthroid). In myxedema coma, there is severe hypothyroidism leading to altered mental status, hypothermia, and organ failure. Administering levothyroxine is crucial to replace the deficient thyroid hormone rapidly and restore metabolic function. Warming the client (B) is important but secondary to addressing the underlying hormonal imbalance. Measuring intake and output (C) is essential for overall assessment but not the most critical intervention. Maintaining a patent airway (D) is always important in any medical emergency but does not directly address the primary issue of hypothyroidism in myxedema coma.
Question 8 of 9
A client with advanced liver cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to prescribe:
Correct Answer: B
Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5-FU). Fluorouracil is a commonly used chemotherapy drug for treating advanced liver cancer. It works by inhibiting the growth of cancer cells. This drug is specifically effective in targeting rapidly dividing cells, which is a characteristic of cancer cells. Fluorouracil is often used in combination with other chemotherapy drugs to improve treatment outcomes. Summary of other choices: A: Fluoxymesterone (Halotestin) - This is an androgen hormone used to treat certain types of breast cancer, not liver cancer. C: Tamoxifen (Nolvadex) - This is a hormonal therapy drug used in breast cancer, not liver cancer. D: Megestrol (Megace) - This is a hormonal therapy drug used for certain types of cancers, but not typically for liver cancer.
Question 9 of 9
Early this morning a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who has now nausea, a temperature of 105F (40.5C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
Correct Answer: C
Rationale: The correct answer is C: Thyroid crisis. These signs suggest thyroid storm, a life-threatening complication of thyroid surgery. The high fever, tachycardia, and restlessness are classic symptoms. Thyroid crisis can lead to severe complications if not managed promptly. A: Diabetic ketoacidosis typically presents with polyuria, polydipsia, and fruity breath odor. B: Hypoglycemia would present with symptoms like diaphoresis, tremors, and confusion. D: Tetany is associated with hypocalcemia and presents with muscle cramps, spasms, and numbness.