ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 9
A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
Correct Answer: D
Rationale: The correct answer is D, as exercise and a weight reduction diet are essential components in managing type 2 diabetes. Exercise helps lower blood glucose levels and improves insulin sensitivity. Weight reduction reduces insulin resistance. Choice A is incorrect because maintaining blood glucose levels between 180-200mg/dl is too high and can lead to complications. Choice B is incorrect as complete smoking cessation is crucial for overall health and diabetes management. Choice C is incorrect because eye examinations should be done annually, not every 2 years, to monitor for diabetic retinopathy. In summary, choice D is the best option as it directly addresses the management of type 2 diabetes.
Question 2 of 9
A client, age 42, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?
Correct Answer: D
Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV is a known risk factor for cervical cancer as it can lead to cellular changes in the cervix. Here's the rationale: 1. HPV is a sexually transmitted infection that can cause abnormal cell growth in the cervix. 2. Persistent HPV infection is a major risk factor for developing cervical cancer. 3. Age 32 is within the typical age range for HPV infection and the development of cervical cancer. 4. Choices A, B, and C are unrelated to the primary risk factor for cervical cancer, which is HPV infection.
Question 3 of 9
The nurse is teaching a client with type 1 diabetes mellitus how to treat adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate. However, this treatment isn’t always a possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
Correct Answer: C
Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.
Question 4 of 9
Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
Correct Answer: A
Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank. Rationale: 1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway. 2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted. Summary of incorrect choices: B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy. C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation. D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.
Question 5 of 9
The nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
Correct Answer: B
Rationale: The correct answer is B: The client wears a watch and wedding band. This is because metal objects such as watches and jewelry can be hazardous during an MRI scan due to the strong magnetic field, leading to potential movement or heating of the metal objects, causing harm to the client. A: The client lies still - This is important for obtaining clear images during an MRI scan and does not pose a threat to the client. C: The client asks questions - Asking questions during an MRI scan does not pose a direct threat to the client's safety. D: The client hears thumping sounds - Thumping sounds are a normal part of the MRI scan and do not pose a threat to the client's safety.
Question 6 of 9
A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [retrovir]), 200mg PO every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
Correct Answer: C
Rationale: The correct answer is C: "Take zidovudine every 4 hours around the clock." Zidovudine is an antiretroviral medication used to treat HIV/AIDS. It is crucial for the client to adhere to the prescribed dosing schedule to maintain therapeutic blood levels. Taking the medication every 4 hours around the clock helps to ensure consistent levels in the body, maximizing its efficacy. Taking it with meals (choice A) or on an empty stomach (choice B) is not specifically indicated for zidovudine. Choice D is incorrect as taking OTC drugs without consulting a healthcare provider can lead to drug interactions or adverse effects. Hence, choice C is the most appropriate instruction to ensure the client benefits from the medication.
Question 7 of 9
As the surgical incision is closed, who are the personnel in-charge in counting the needles, sponges, and instruments?
Correct Answer: C
Rationale: The correct answer is C - the circulating and scrub nurse first assistant. The circulating nurse is responsible for counting needles, sponges, and instruments during the closing of the surgical incision to ensure nothing is left inside the patient. The scrub nurse first assistant also plays a crucial role in this process by assisting in the counting and keeping track of the items used during the procedure. The other choices are incorrect because the surgeon and anesthesiologist (A) are not typically involved in counting items during the surgical closure, the surgeon and the registered (B) may not have the necessary training for accurate counting, and the anesthesiologist and anesthetist (D) are not directly involved in the surgical closing process.
Question 8 of 9
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
Correct Answer: B
Rationale: The correct answer is B because decorticate posturing is characterized by the flexion of elbows, wrists, and fingers, extension of elbows and knees, plantar flexion of feet. This pattern indicates damage to the cerebral hemispheres or internal structures of the brain. In contrast, option A describes decerebrate posturing, which indicates more severe brain damage. Option C is incorrect as it describes a mixed pattern of posturing. Option D is also incorrect as it describes a different type of posturing called decerebrate posturing.
Question 9 of 9
While managing a client after a medical or surgical procedure for bladder stones, for what rise in the temperature should the nurse notify the physician?
Correct Answer: C
Rationale: The correct answer is C: When the temperature rises above 102F. A temperature rise above 102F is concerning as it may indicate infection or other complications post-procedure. This higher threshold helps in early detection and timely intervention. Choices A and B set lower thresholds, potentially delaying necessary medical attention. Choice D is below the typical threshold for fever and would not typically warrant physician notification in this context.