Questions 9

ATI RN

ATI RN Test Bank

Nursing Process Questions and Answers PDF Questions

Question 1 of 5

A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?

Correct Answer: D

Rationale: The correct answer is D: Shallow breathing and increasing lethargy. This finding could indicate a potential respiratory complication such as atelectasis or pneumonia, which are common postoperative complications. Shallow breathing can lead to inadequate oxygenation and ventilation, causing lethargy due to decreased oxygen delivery to tissues. It is crucial to assess and address respiratory issues promptly to prevent further complications. A: Abdominal pain is expected postoperatively and can be managed with pain medications. B: Serous drainage from the incision is a normal finding after surgery and indicates the wound is healing properly. C: Hypoactive bowel sounds are common after surgery due to decreased peristalsis and can be managed with interventions such as early ambulation and medications.

Question 2 of 5

The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?

Correct Answer: D

Rationale: The correct answer is D because the absence of skin breakdown indicates that the turning schedule was effective in preventing pressure ulcers. Skin breakdown is a key indicator of pressure ulcer development, so its absence suggests that the patient's skin integrity was maintained. Choice A is incorrect because documentation alone does not guarantee successful prevention. Choice B is incorrect as redness on the heels can still indicate the early stages of pressure ulcers. Choice C is unrelated to skin integrity and pressure ulcer prevention.

Question 3 of 5

A 58-year-old man is diagnosed with cancer of the larynx. Which of the ff. are early symptoms of this cancer?

Correct Answer: D

Rationale: The correct answer is D: Dysphagia or hoarseness. In laryngeal cancer, dysphagia and hoarseness are early symptoms due to vocal cord involvement. Hoarseness results from vocal cord paralysis, while dysphagia occurs when the tumor obstructs the esophagus. Anemia and fatigue (choice A) are nonspecific symptoms seen in various conditions. A noticeable lump in the neck (choice B) typically indicates metastasis to the lymph nodes, which occurs later in laryngeal cancer. Crackles and stridor (choice C) are more associated with respiratory conditions rather than laryngeal cancer.

Question 4 of 5

A nurse is conducting a nursing health history. Which component will the nurse address?

Correct Answer: B

Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for care. By focusing on the patient's expectations, the nurse can provide patient-centered care and tailor interventions to meet the patient's specific needs. A: Nurse's concerns - While it is important for the nurse to consider their own concerns, the primary focus should be on the patient's needs and expectations. C: Current treatment orders - This is important information to gather, but it does not directly address the patient's expectations or preferences. D: Nurse's goals for the patient - The nurse should work collaboratively with the patient to establish goals that align with the patient's expectations and preferences, rather than imposing their own goals.

Question 5 of 5

What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?

Correct Answer: A

Rationale: The correct answer is A. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process. B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully. C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood. D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.

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