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
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 3 of 9
A client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?
Correct Answer: A
Rationale: The correct answer is A: Surgery. Surgery is the primary treatment for vaginal cancer, especially for early-stage cases. It involves removing the cancerous tissue from the vagina. Radiation (B) and chemotherapy (C) may also be used in addition to surgery in some cases, but they are not the primary treatment. Immunotherapy (D) is not a standard treatment for vaginal cancer. It is important to prioritize surgery as it directly targets and removes the cancerous cells from the affected area, increasing the chances of successful treatment and recovery.
Question 4 of 9
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
Correct Answer: C
Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.
Question 5 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 6 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 7 of 9
A patient complains of tingling in his fingers. He has positive Trousseau’s and Chvostek’s signs. He says that he feels depressed. Choose the most likely serum calcium (Ca ) value for this patient:
Correct Answer: A
Rationale: The correct answer is A: 11mg/dl. This patient is likely experiencing hypocalcemia, indicated by positive Trousseau's and Chvostek's signs. These signs suggest neuromuscular irritability due to low calcium levels. A serum calcium level of 11mg/dl is higher than normal, indicating possible hyperparathyroidism causing high calcium levels. Choices B, C, and D are lower than normal, which would exacerbate symptoms rather than alleviate them.
Question 8 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 with a broad assessment of the surgical dressing and the type of drainage present, then will progress to more specific assessments based on the findings. This approach allows for a systematic and comprehensive evaluation of the patient's condition by moving from general observations to detailed examinations. Explanation: 1. General assessment: The nurse is initially assessing the overall appearance of the surgical dressing and the type of drainage. 2. Specific assessment: Based on the initial findings, the nurse will proceed to conduct more focused assessments, such as checking for signs of infection, monitoring vital signs, and assessing the surgical site for any complications. Other choices are incorrect: A: Gordon’s Functional Health Patterns - This framework focuses on assessing different aspects of an individual's health patterns, such as activity level, sleep patterns, and coping mechanisms. It is not the most appropriate approach in this situation. B: Activity-exercise pattern assessment - This type of assessment focuses
Question 9 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. This type of assessment approach involves starting with a broad overview of the patient's condition and then narrowing down to specific details. In this scenario, the nurse begins by examining the surgical dressing, which is a specific aspect of the patient's condition, after which they can proceed to gather more detailed information about the drainage, wound healing, and any associated symptoms. This approach allows the nurse to systematically assess the patient's postoperative status and identify any potential issues. A: Gordon’s Functional Health Patterns is a comprehensive framework for organizing patient data, but it does not specifically address the sequence of assessment in this scenario. B: Activity-exercise pattern assessment focuses on the patient's activity level and exercise habits, which is not the primary concern in this situation. D: Problem-oriented assessment involves identifying and addressing specific health problems, but it does not capture the systematic progression from general to specific assessment as seen in this scenario.