ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 9
A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?
Correct Answer: C
Rationale: The correct answer is C: “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.” Rationale: 1. Desmopressin is available in intranasal form for diabetes insipidus. 2. Nasal discharge or blockage may prevent proper absorption of the medication. 3. Instructing the client about this potential issue ensures optimal drug effectiveness. Summary: A: Incorrect. Temperature of desmopressin suspension doesn't affect its efficacy. B: Incorrect. A medical identification bracelet is necessary for chronic conditions like diabetes insipidus. D: Incorrect. Monitoring fluid intake and output is crucial when taking desmopressin.
Question 2 of 9
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
Correct Answer: D
Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications. Summary: A: Lungs - Not directly affected by potassium levels. B: Liver - Not directly affected by potassium levels. C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.
Question 3 of 9
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
Correct Answer: D
Rationale: The correct answer is D: Patency of airway and adequacy of respiration. During the acute stage of an unconscious patient like Mr. Franco, ensuring the airway is open and that breathing is adequate is the top priority to maintain oxygenation and prevent complications like hypoxia. This assessment is crucial for immediate intervention and can be life-saving. A: Level of awareness and response to pain may provide important information but is secondary to ensuring a patent airway and adequate breathing in an unconscious patient. B: Pupillary reflexes and response to sensory stimuli are important neurological assessments, but airway and breathing take precedence in the acute stage to maintain vital functions. C: Coherence and sense of hearing are not as critical as assessing and maintaining the airway and breathing in an unconscious patient.
Question 4 of 9
Hypernatremia is associated with a:
Correct Answer: D
Rationale: Step 1: Hypernatremia is defined by elevated serum sodium levels (>145mEq/L). Step 2: Serum osmolality of 245mOsm/kg is high, consistent with hypernatremia. Step 3: Urine specific gravity below 1.003 indicates dilute urine, a common finding in hypernatremia. Step 4: The combination of elevated serum sodium, high serum osmolality, and low urine specific gravity confirms hypernatremia. Summary: A: Incorrect, as high serum osmolality (not 245mOsm/kg) is associated with hypernatremia. B: Incorrect, as low urine specific gravity (not below 1.003) is seen in hypernatremia. C: Incorrect, as serum sodium needs to be >145mEq/L to indicate hypernatremia.
Question 5 of 9
The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
Correct Answer: B
Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery. A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.
Question 6 of 9
Which nursing diagnosis is most appropriate for a client with Addison’s disease?
Correct Answer: C
Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.
Question 7 of 9
Why must clients who will undergo diagnostic skin test avoid taking antihistamine or cold preparations for at least 48-72 hrs before testing?
Correct Answer: C
Rationale: The correct answer is C because antihistamines can suppress the immune response that the skin test is designed to detect, leading to false negative results. By inhibiting the body's allergic response, antihistamines can mask the presence of an allergy, giving the false impression that the individual is not allergic to a particular substance. This can lead to misdiagnosis and improper treatment. Choices A, B, and D are incorrect because antihistamines do not affect bleeding, aggravate allergic reactions, or cause wheezing in the context of a skin test.
Question 8 of 9
Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?
Correct Answer: D
Rationale: Rationale: 1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system. 2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema. 3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution. Summary: A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration. B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect. C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect. D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid
Question 9 of 9
Which of the following medications should then nurse explain may cause headache as a side effect?
Correct Answer: B
Rationale: The correct answer is B: Clonidine (Catapres). Clonidine is known to cause headache as a side effect due to its mechanism of action affecting blood pressure regulation in the brain. Furosemide (A) is a diuretic that typically causes electrolyte imbalances, not headaches. Atenolol (C) is a beta-blocker used for hypertension, which can cause fatigue but not typically headaches. Adalat (D) is a calcium channel blocker that usually causes peripheral edema, not headaches.