ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?
Correct Answer: B
Rationale: The correct answer is B: "Take ferrous sulfate and the antacid at least 2 hours apart." Rationale: 1. Iron absorption is decreased in the presence of antacids due to decreased gastric acidity. 2. Antacids can bind to iron and reduce its absorption. 3. Taking them 2 hours apart allows for optimal iron absorption without interference from the antacid. 4. Taking them together (choice A) would decrease iron absorption. 5. Avoiding antacids altogether (choice C) may not be necessary if spaced apart appropriately. 6. Taking them 1 hour apart (choice D) may still lead to decreased iron absorption due to antacid interference.
Question 2 of 5
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100mcg IM daily. Which substance influences Vitamin B12 absorption?
Correct Answer: A
Rationale: Rationale: Intrinsic factor is a glycoprotein produced by the stomach that is essential for the absorption of vitamin B12 in the ileum. Without intrinsic factor, vitamin B12 absorption is impaired, leading to megaloblastic anemia. Histamine and hydrochloric acid are not directly involved in vitamin B12 absorption. Liver enzymes are not implicated in the absorption process. Therefore, the correct answer is A.
Question 3 of 5
Which laboratory study is monitored for the patient receiving heparin therapy?
Correct Answer: B
Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect. A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin. C: PT (Prothrombin Time) is also used to monitor warfarin therapy. D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.
Question 4 of 5
Which of the ff. interventions can help minimize complications related to Hypercalcemia?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Hypercalcemia can lead to dehydration due to increased urine output. 2. Encouraging 3 to 4 L of fluid daily helps prevent dehydration and promote renal excretion of excess calcium. 3. Adequate hydration reduces the risk of kidney stones and other complications associated with hypercalcemia. Summary of why other choices are incorrect: - Choice B (bed rest) does not directly address hypercalcemia complications. - Choice C (cough and deep breathe) is unrelated to managing hypercalcemia. - Choice D (apply heat to painful areas) does not address the underlying cause of hypercalcemia or its complications.
Question 5 of 5
An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
Correct Answer: A
Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.