Questions 9

ATI RN

ATI RN Test Bank

ADPIE Nursing Process Questions Questions

Question 1 of 5

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?

Correct Answer: A

Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. This is because soap can irritate the skin, leading to skin breakdown in a client at risk for impaired skin integrity due to radiation therapy. Avoiding soap helps to prevent further damage to the skin. Choice B is incorrect as talcum powder can further irritate the skin and should be avoided. Choice C is not relevant to preventing skin integrity issues. Choice D is incorrect because thoracic skin markings should not be removed as they are essential for accurate radiation delivery.

Question 2 of 5

Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?

Correct Answer: B

Rationale: The correct answer is B: Administer 6L of IV fluid over the first 24 hours. In HHNS, dehydration is severe due to high blood glucose levels causing osmotic diuresis. Rapid infusion of fluid can lead to fluid overload and exacerbate the situation. Administering 6L over 24 hours helps gradually replenish lost fluids without causing circulatory overload. Choice A is incorrect because rapid infusion can lead to fluid overload. Choice C is incorrect because adding dextrose to the solution can further increase blood glucose levels. Choice D is incorrect because administering IV fluids slowly can delay rehydration in a critical situation like HHNS.

Question 3 of 5

Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:

Correct Answer: D

Rationale: The correct answer is D: 24 hours. Compartment syndrome occurs when pressure within a closed muscle compartment increases, leading to decreased circulation and potential tissue damage. Monitoring is crucial as irreversible damage can occur if left untreated. The 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, pressure) are key indicators. Waiting for 48 hours (choice A) or 12 hours (choice C) is too long and can result in severe consequences. 2 hours (choice B) is too short a timeframe to assess for irreversible damage development, making 24 hours (choice D) the most appropriate timeframe for monitoring and intervention.

Question 4 of 5

A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client’s history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:

Correct Answer: D

Rationale: The correct answer is D: Cryptorchidism. Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer as the testicle does not descend into the scrotum during fetal development, increasing the risk of cancer development. Testosterone therapy during childhood (A) and early onset of puberty (B) are not directly linked to testicular cancer. Sexually transmitted diseases (C) typically do not increase the risk of testicular cancer. Therefore, choice D is the most relevant risk factor for testicular cancer in this scenario.

Question 5 of 5

Why does the nurse instruct the client to avoid Valsalva maneuvers?

Correct Answer: B

Rationale: The correct answer is B because performing Valsalva maneuver can lead to a sudden drop in blood pressure, causing the client to lose consciousness. This occurs due to the increased intra-abdominal pressure leading to decreased venous return to the heart. Choices A, C, and D are incorrect as they do not accurately reflect the consequences of Valsalva maneuver. Option A stating that the client's blood pressure will decrease momentarily is incorrect as it actually increases initially. Option C suggesting that the client may suffer from a myocardial infarction is incorrect as Valsalva maneuver does not directly cause heart attacks. Option D implying that the client's blood pressure will increase momentarily is also incorrect as the immediate effect is a rise followed by a significant drop.

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