ATI RN
Nursing Process Questions Questions
Question 1 of 9
A client reports difficulty breathing, stating, 'I can’t catch my breath.' What is the most appropriate action for the nurse to take?
Correct Answer: A
Rationale: The correct answer is A because measuring oxygen saturation will provide objective data to assess the client's respiratory status accurately. This step is crucial in identifying the severity of the client's breathing difficulty and determining the appropriate intervention. Encouraging deep breathing exercises (B) may worsen the client's condition if there is an underlying respiratory problem. Simply documenting the client's statement (C) without immediate action can delay necessary interventions. Providing oxygen without further assessment (D) can be harmful if the client's oxygen saturation is already high. Overall, option A is the most appropriate as it involves a proactive and evidence-based approach to address the client's reported breathing difficulty.
Question 2 of 9
A patient has orders to receive 1 L (1000 mL) of 5% dextrose and lactated Ringer’s solution to be infused over 8 hours. How many millilitres will be infused per hour?
Correct Answer: C
Rationale: The correct answer is C: 125 mL/h. To calculate the infusion rate per hour, we divide the total volume (1000 mL) by the total time in hours (8 hours). 1000 mL / 8 hours = 125 mL/h. This ensures a consistent and accurate infusion rate throughout the 8-hour period. Choice A (80 mL/h) is incorrect because it underestimates the infusion rate. Choice B (100 mL/h) is incorrect because it does not divide the total volume by the total time correctly. Choice D (150 mL/h) is incorrect because it overestimates the infusion rate.
Question 3 of 9
A seizure characterized by loss of consciousness and tonic spasms of the trunk and extremities rapidly followed by repetitive generalized clonic jerking is classified as:
Correct Answer: C
Rationale: The correct answer is C: Generalized seizure. This type of seizure involves both hemispheres of the brain from the onset, leading to loss of consciousness and tonic-clonic jerking. It is characterized by widespread, synchronized electrical discharges. A: Focal seizures start in one area of the brain, leading to localized symptoms without loss of consciousness. B: Jacksonian seizures are a type of focal seizure characterized by a progression of jerking movements from one body part to another. D: Partial seizures involve only one part of the brain, leading to localized symptoms or altered consciousness without loss of awareness.
Question 4 of 9
If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
Correct Answer: B
Rationale: The correct answer is B because right-sided weakness is typically associated with damage or impairment in the left lobe of the brain. The brain controls the opposite side of the body, so weakness on the right side indicates left brain involvement. This is known as contralateral control. The other choices are incorrect because expressive aphasia is associated with left brain damage, problems in judging distance and proprioception are related to parietal lobe damage, and orientation to time and space is more related to frontal lobe damage. Therefore, the most accurate analysis by the nurse would be to consider the affected lobe as the right lobe in this case.
Question 5 of 9
Nurse Raymond is handling a group of student nurses and he is teaching them about fluids and electrolytes. He is correct when he says that a substance moves from an area of higher concentration, this is:
Correct Answer: C
Rationale: Correct Answer: C - Diffusion Rationale: Diffusion is the movement of a substance from an area of higher concentration to an area of lower concentration. This process occurs naturally to achieve equilibrium. In the context of fluids and electrolytes, this movement helps maintain balance within the body. Unlike osmosis, which involves the movement of water molecules across a semi-permeable membrane, diffusion applies to the movement of all types of substances. Filtration involves the movement of substances through a barrier under pressure, and active transport requires energy to move substances against a concentration gradient. Therefore, the correct answer is diffusion as it aligns with the principle of movement from high to low concentration for achieving equilibrium.
Question 6 of 9
Clinical manifestations of Huntington’s disease include:
Correct Answer: D
Rationale: The correct answer is D because Huntington's disease is a neurodegenerative disorder that presents with a triad of symptoms: abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Chorea is a hallmark feature of Huntington's disease, caused by damage to the basal ganglia. Intellectual decline includes cognitive impairments such as memory loss and executive dysfunction. Emotional disturbances involve mood swings, irritability, and apathy. Therefore, all three manifestations are commonly seen in individuals with Huntington's disease, making D the correct choice. Choices A, B, and C are incorrect individually because they do not encompass all the key clinical features of Huntington's disease.
Question 7 of 9
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
Correct Answer: A
Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.
Question 8 of 9
The couple with the lowest risk of having a child with sickle cell disease is the one in which the:
Correct Answer: D
Rationale: The correct answer is D because sickle cell disease is an autosomal recessive genetic disorder. The disease is caused by inheriting two copies of the abnormal hemoglobin gene (HbS). In choice D, the father is HbA (normal) and the mother is HbS (carrier). This combination ensures that the child will inherit one normal gene and one abnormal gene, making them a carrier like the mother but not affected by the disease. Choices A, B, and C all involve at least one parent who carries the HbS gene, increasing the risk of the child having sickle cell disease.
Question 9 of 9
Following the American Cancer Society guidelines, the nurse should recommend that the women:
Correct Answer: C
Rationale: The correct answer is C because the American Cancer Society recommends women to have a mammogram annually starting at age 45, then have the option to transition to biennial screening at age 55. This recommendation is based on evidence that regular mammograms can help detect breast cancer early, increasing chances of successful treatment. Choice A is incorrect because self-examinations are no longer recommended as a routine screening method. Choice B is incorrect as clinical breast exams are not as effective as mammograms for detecting breast cancer. Choice D is incorrect as normal receptor assays are not part of routine breast cancer screening guidelines.