ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
A client who suffered a vehicular accident a few days ago is in skeletal traction. Which nursing action would BESt promote INDEPENDENCE for this patient?
Correct Answer: B
Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.
Question 2 of 5
As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Anaphylaxis is a severe allergic reaction that can lead to airway constriction and difficulty breathing, resulting in wheezing. Wheezing is a common symptom of anaphylaxis due to bronchospasm and airway swelling. Dermatitis (A) is a skin reaction, sinusitis (B) is inflammation of the sinuses, and delirium (C) is a state of mental confusion, which are not typical symptoms of anaphylaxis. Wheezing is a critical symptom in anaphylaxis as it indicates potential airway compromise and the need for immediate medical intervention.
Question 3 of 5
After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data?
Correct Answer: A
Rationale: The correct answer is A because auscultation of the lungs involves direct observation and measurement, making it objective data. This data is based on what the nurse hears through the stethoscope, which can be verified and measured. Choices B, C, and D involve subjective experiences or interpretations that cannot be directly observed or measured. Complaint of nausea, sensation of burning, and belief in demons are all based on the client's feelings, perceptions, or beliefs, which are subjective and can vary from person to person. Objective data is factual, measurable, and observable, making choice A the correct answer in this scenario.
Question 4 of 5
A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
Correct Answer: A
Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.
Question 5 of 5
An agitated, confused client arrives in the emergency department. The client’s history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
Correct Answer: C
Rationale: The correct answer is C: 10 to 15 g of a simple carbohydrate. This amount of carbohydrate is recommended for treating hypoglycemia in clients with diabetes to quickly raise blood glucose levels without causing hyperglycemia. Consuming too little carbohydrate may not effectively raise blood glucose levels, while consuming too much may lead to a rapid spike followed by a rebound hypoglycemia. Options A and B provide insufficient amounts of carbohydrate, while option D provides excessive carbohydrate, increasing the risk of hyperglycemia. Therefore, option C is the most appropriate choice for effectively treating hypoglycemia in this client.
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