ATI RN
Nursing Process Practice Questions Questions
Question 1 of 9
A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery-this will go away on its own”. In considering her response to the client, the nurse must depend on the ethical principle of:
Correct Answer: C
Rationale: The correct answer is C: Autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their own healthcare. In this scenario, the client is expressing her desire to not undergo surgery, which is her right as an autonomous individual. The nurse must respect her decision even if it goes against medical advice. Beneficence (A) is the ethical principle of doing good for the patient, but in this case, respecting the client's autonomy takes precedence. Advocacy (B) involves supporting the client's best interests, which could align with autonomy in this case. Justice (D) refers to fairness and equal treatment, but it is not directly applicable to the client's decision regarding surgery.
Question 2 of 9
Which of the following is classified as subjective data in a nursing assessment?
Correct Answer: B
Rationale: The correct answer is B because subjective data in a nursing assessment refers to information provided by the patient, such as feelings, perceptions, and symptoms. In this case, the client stating 'I feel nauseated' represents subjective data. This type of information cannot be measured or observed directly. A, C, and D are incorrect: A: Heart rate of 90 beats per minute is an objective measurement that can be directly observed. C: Blood pressure of 130/80 mmHg is also an objective measurement that can be directly observed. D: Skin appears flushed is an objective observation that can be directly seen.
Question 3 of 9
The normal life expectancy for 50% of patients ith amyotropic lateral sclerosis (ALS) is:
Correct Answer: C
Rationale: The correct answer is C: 5 years. In ALS, 50% of patients have a life expectancy of around 3-5 years from the time of diagnosis. This is due to the progressive nature of the disease, leading to rapid deterioration of motor neurons and muscle function. Choice A (3 years) is too specific and may not apply to exactly 50% of patients. Choice B (10 years) and D (20 years) are too optimistic and do not align with the typical prognosis of ALS, where the majority of patients have a shorter life expectancy. Therefore, based on the average survival rates and disease progression, choice C is the most accurate representation of the normal life expectancy for 50% of ALS patients.
Question 4 of 9
Choose the condition th₃a⁻t exhibits blood values with a low pH and a low plasma bicarbonate concentration:
Correct Answer: B
Rationale: Step-by-step rationale: 1. Metabolic acidosis is characterized by low pH and low plasma bicarbonate. 2. In this condition, there is an excess of acids or a loss of bicarbonate. 3. The kidneys are unable to adequately excrete acids or retain bicarbonate. 4. This leads to a decrease in bicarbonate levels and a decrease in pH. 5. Respiratory acidosis (A) is characterized by low pH and high CO2 levels. 6. Respiratory alkalosis (C) is characterized by high pH and low CO2 levels. 7. Metabolic alkalosis (D) is characterized by high pH and high bicarbonate levels. Summary: - Choice A is incorrect as it describes a condition with high CO2 levels. - Choice C is incorrect as it describes a condition with high pH. - Choice D is incorrect as it describes a condition with high bicarbonate levels. - Choice B is correct as it accurately describes the characteristics of a condition with low pH
Question 5 of 9
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.
Question 6 of 9
The nurse knows which of the following is true about immunity?
Correct Answer: C
Rationale: Rationale: Choice C is correct because antibodies are indeed produced by B-cells as part of the adaptive immune response. B-cells differentiate into plasma cells that produce antibodies to target specific antigens. This process is essential for generating immunity against pathogens. Incorrect Choices: A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity. B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. T-cells directly attack infected cells. D: Lymphocytes can increase during an allergic response, but this does not specifically relate to immunity through antibody production by B-cells.
Question 7 of 9
During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
Correct Answer: B
Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health. A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment. C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses. D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.
Question 8 of 9
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
Correct Answer: D
Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on their scope of practice, which involves identifying and addressing the patient's nursing care needs. By formulating a specific nursing diagnosis, nurses can prioritize interventions and provide individualized care. Choice A is incorrect as nursing diagnoses are not exclusive to nurses. Choice B is incorrect because nursing and physician roles overlap. Choice C is incorrect as clinical judgment should be based on evidence and critical thinking, not solely on intuition.
Question 9 of 9
Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
Correct Answer: D
Rationale: Rationale: - Choice D is correct as it offers the patient autonomy and promotes self-care, which is important for maintaining independence and dignity. - By giving the patient a choice between brushing their own teeth or having assistance, it empowers them to make decisions. - Choices A, B, and C are not as appropriate because they do not address the patient's autonomy and may come across as directive or intrusive, which can further exacerbate the altered thought process.