Questions 9

ATI RN

ATI RN Test Bank

Nursing Process NCLEX Questions Questions

Question 1 of 5

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?

Correct Answer: C

Rationale: Rationale: 1. Anemia results in decreased oxygen-carrying capacity, leading to tissue hypoxia. 2. Dyspnea (shortness of breath) occurs due to the body's attempt to increase oxygen intake. 3. Tachycardia (rapid heart rate) compensates for decreased oxygen delivery. 4. Pallor (pale skin) is a classic sign of decreased red blood cells in iron-deficiency anemia. Summary: A: Night sweats, weight loss, and diarrhea are not typical manifestations of iron-deficiency anemia. B: Nausea, vomiting, and anorexia are non-specific symptoms and not specific to iron-deficiency anemia. D: Itching, rash, and jaundice are not commonly associated with iron-deficiency anemia.

Question 2 of 5

When preparing a site for venipunctures with alcohol, how long must the area be cleaned?

Correct Answer: D

Rationale: The correct answer is D: 60 seconds. This is because the area must be cleaned for at least 60 seconds to effectively disinfect the skin and reduce the risk of infection during venipuncture. Cleaning for shorter durations (5, 10, or 30 seconds) may not be sufficient to achieve proper disinfection. Thoroughly cleaning the area for a full minute ensures that the alcohol has enough time to kill bacteria and pathogens on the skin, making it safer for the venipuncture procedure. Shorter cleaning times may leave pathogens behind, increasing the risk of contamination and infection.

Question 3 of 5

A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?

Correct Answer: C

Rationale: Rationale for Correct Answer (C): A complete blood count (CBC) is used to identify abnormalities in red blood cells, white blood cells, and platelets. Hematocrit (HCT) and hemoglobin (Hb) levels are part of a CBC and indicate the oxygen-carrying capacity of the blood. Abnormally low HCT and Hb levels can signify conditions like anemia, which can impact a client's ability to undergo surgery due to potential complications related to oxygen delivery. Summary of Incorrect Choices: A: Potential hepatic dysfunction is not directly related to a CBC, and BUN/creatinine levels are markers for kidney function, not liver function. B: Low levels of urine constituents are not assessed in a CBC, which focuses on blood components. D: Electrolyte imbalance is not specifically tested in a CBC; it is usually evaluated through separate blood tests. Coagulation factors are not directly measured in a CBC.

Question 4 of 5

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Correct Answer: A

Rationale: The correct answer is A because the first phase of the nursing process is assessment, where the nurse gathers comprehensive data about the patient's health status. This step is crucial in identifying problems and setting priorities for care. Choice B comes in the second phase (diagnosis), C in the third phase (planning), and D in the last phase (evaluation). Assessing the patient's condition is the foundation for the rest of the nursing process.

Question 5 of 5

Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, “Why?” Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?

Correct Answer: C

Rationale: The correct answer is C: Pneumonia. Early postoperative ambulation helps prevent pneumonia by promoting lung expansion, increasing oxygenation, and preventing atelectasis. A: Increased peristalsis is unrelated to ambulation. B: Coughing is important for airway clearance but not directly related to ambulation. D: Wound healing is influenced by various factors, but ambulation primarily impacts respiratory function.

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