ATI RN
Nursing Process Test Bank Questions
Question 1 of 9
A client metastatic ovarian cancer is prescribed cisplatin (Platinol). Before administering the first dose, the nurse reviews the client’s medication history for drugs that may interact with cisplatin. Which drug may cause significant interactions when given concomitantly with cisplatin?
Correct Answer: D
Rationale: The correct answer is D: An aminoglycoside. Aminoglycosides, such as gentamicin or amikacin, can interact with cisplatin by increasing the risk of nephrotoxicity and ototoxicity. Both cisplatin and aminoglycosides have the potential to cause kidney damage, and when used together, the risk of kidney toxicity is significantly increased. This interaction is due to the additive effects on the kidneys. Therefore, it is crucial to monitor renal function closely and adjust the dosages of these drugs accordingly to prevent severe adverse effects. Summary: A: Erythromycin - Erythromycin is not known to have significant interactions with cisplatin. B: A cephalosporin - Cephalosporins do not typically interact with cisplatin in a clinically significant manner. C: A tetracycline - Tetracyclines are not known to cause significant interactions with
Question 2 of 9
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?
Correct Answer: D
Rationale: The correct answer is D: Sitting at a 45-degree angle to the bed. This position allows the nurse to have a clear view of the client and maintain good communication. Sitting at a 45-degree angle enables the nurse to observe the client's facial expressions, body language, and interact effectively. Standing at the end of the bed (A) limits the nurse's view and communication. Standing at the side of the bed (B) may obstruct the nurse-client interaction. Sitting at least six feet away (C) creates unnecessary distance and hinders effective communication.
Question 3 of 9
Which immunoglobulin is specific to an allergic response?
Correct Answer: B
Rationale: The correct answer is B: IgE. IgE is specific to allergic responses as it binds to mast cells and basophils, triggering the release of histamine and other inflammatory mediators. IgA is more involved in mucosal immunity, IgG is involved in long-term immunity and opsonization, and IgM is the primary antibody in the primary immune response. IgB is not a known immunoglobulin. Therefore, IgE is the specific immunoglobulin associated with allergic responses due to its role in mediating hypersensitivity reactions.
Question 4 of 9
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, which are signs and symptoms that support the diagnosis. This helps to differentiate it from other types of diagnoses such as risk, possible, or wellness diagnoses. Risk nursing diagnoses predict potential problems, possible nursing diagnoses lack sufficient data for validation, and wellness diagnoses focus on promoting health rather than addressing current health issues. Therefore, only the actual nursing diagnosis is confirmed by the presence of observable defining characteristics.
Question 5 of 9
A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?
Correct Answer: A
Rationale: The correct answer is A because playing card games with friends is a low-energy activity suitable for someone with decreased energy due to chemotherapy. This option promotes social interaction and mental stimulation, addressing the deficient diversional activity. B, bowling with a team, involves physical activity and may be too strenuous for someone with decreased energy. C, taking a long trip, requires significant energy and may not be feasible. D, eating lunch in a restaurant, does not address the need for diversional activity and is not specific to the client's energy limitations.
Question 6 of 9
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: providing for frequent rest periods. This intervention is essential for a client with radiation-induced thrombocytopenia to prevent further platelet depletion and reduce the risk of bleeding episodes. Rest periods help conserve energy and minimize physical exertion, which can trigger bleeding in thrombocytopenic clients. Rationale: 1. Administering aspirin (choice A) is contraindicated in thrombocytopenia as it can further decrease platelet count and increase the risk of bleeding. 2. Inspecting the skin for petechiae (choice B) is important but not as crucial as providing rest periods in managing thrombocytopenia. 3. Placing the client in strict isolation (choice D) is not necessary for radiation-induced thrombocytopenia unless there are other specific infectious concerns. In summary, providing frequent rest periods is the most appropriate intervention to manage radiation-induced thrombocytopenia, promoting patient
Question 7 of 9
A client metastatic ovarian cancer is prescribed cisplatin (Platinol). Before administering the first dose, the nurse reviews the client’s medication history for drugs that may interact with cisplatin. Which drug may cause significant interactions when given concomitantly with cisplatin?
Correct Answer: D
Rationale: The correct answer is D: An aminoglycoside. Aminoglycosides, such as gentamicin or amikacin, can interact with cisplatin by increasing the risk of nephrotoxicity and ototoxicity. Both cisplatin and aminoglycosides have the potential to cause kidney damage, and when used together, the risk of kidney toxicity is significantly increased. This interaction is due to the additive effects on the kidneys. Therefore, it is crucial to monitor renal function closely and adjust the dosages of these drugs accordingly to prevent severe adverse effects. Summary: A: Erythromycin - Erythromycin is not known to have significant interactions with cisplatin. B: A cephalosporin - Cephalosporins do not typically interact with cisplatin in a clinically significant manner. C: A tetracycline - Tetracyclines are not known to cause significant interactions with
Question 8 of 9
A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
Correct Answer: B
Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications. A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances. C: Hyperchloremia is not a common concern in this scenario based on the given lab values. D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.
Question 9 of 9
Which of the following is an important preventive factor that the nurse should teach a client with rhinitis?
Correct Answer: D
Rationale: The correct answer is D: To wash hands frequently. This is important in rhinitis prevention as it helps reduce the spread of viruses and bacteria that can trigger or exacerbate symptoms. Washing hands removes potential allergens and irritants, reducing the risk of rhinitis flare-ups. Choice A is incorrect as blowing the nose is necessary to clear mucus and alleviate symptoms. Choice B is irrelevant to rhinitis prevention. Choice C is not directly related to preventing rhinitis.