ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 9
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 9
A 19-year-old student develops symptoms of respiratory alkalosis related to an anxiety attack. Which nursing intervention is appropriate?
Correct Answer: B
Rationale: The correct answer is B: Have him breathe into a paper bag. Breathing into a paper bag helps increase the carbon dioxide levels in the blood, which can help reverse respiratory alkalosis caused by hyperventilation during an anxiety attack. This intervention helps to normalize the blood pH and alleviate symptoms. Incorrect choices: A: Making sure oxygen is administered as ordered is not appropriate for respiratory alkalosis due to hyperventilation. Oxygen therapy can worsen the condition by further reducing carbon dioxide levels. C: Placing the student in a semi-fowler's position does not directly address the primary issue of respiratory alkalosis and anxiety-induced hyperventilation. D: Coughing and deep breathing exercises may exacerbate the hyperventilation and worsen the respiratory alkalosis rather than alleviate the symptoms.
Question 3 of 9
Which of the ff. interventions can help minimize complications related to Hypercalcemia?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Hypercalcemia can lead to dehydration due to increased urine output. 2. Encouraging 3 to 4 L of fluid daily helps prevent dehydration and promote renal excretion of excess calcium. 3. Adequate hydration reduces the risk of kidney stones and other complications associated with hypercalcemia. Summary of why other choices are incorrect: - Choice B (bed rest) does not directly address hypercalcemia complications. - Choice C (cough and deep breathe) is unrelated to managing hypercalcemia. - Choice D (apply heat to painful areas) does not address the underlying cause of hypercalcemia or its complications.
Question 4 of 9
The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?
Correct Answer: B
Rationale: The correct answer is B: Stage 2 hypertension. The patient's BP readings consistently fall within the range of 160-179 systolic or 100-109 diastolic, which aligns with the criteria for Stage 2 hypertension based on the current guidelines. This classification indicates a higher level of hypertension that requires prompt medical attention and intervention to reduce the risk of complications. Choices A, C, and D are incorrect because they do not correspond to the BP readings provided, falling outside the range for prehypertension, Stage 1 hypertension, and posthypertension.
Question 5 of 9
The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
Correct Answer: A
Rationale: The correct answer is A: Type A. Individuals with blood type A have a slightly higher risk of developing gastric cancer compared to other blood types. This is due to the presence of certain antigens associated with Type A blood that may increase susceptibility to gastric cancer. In this case, the nurse mentions a 10% increased risk for individuals with Type A blood, which aligns with the known epidemiological data. Choice B: Type AB is incorrect because individuals with Type AB blood do not have a known increased risk of gastric cancer. Choice C: Type B is incorrect because individuals with Type B blood do not have a known increased risk of gastric cancer. Choice D: Type O is incorrect because individuals with Type O blood actually have a slightly lower risk of developing gastric cancer compared to individuals with Type A blood.
Question 6 of 9
When caring for a client with diabetes insipidus, the nurse expects to administer:
Correct Answer: A
Rationale: The correct answer is A: Vasopressin (Pitressin Synthetic). In diabetes insipidus, there is a deficiency of ADH (antidiuretic hormone), leading to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps retain water by reducing urine output. Administering vasopressin helps manage the symptoms of diabetes insipidus. B: Regular insulin is used to manage diabetes mellitus, not diabetes insipidus. C: Furosemide is a diuretic used to increase urine output, which would worsen the symptoms of diabetes insipidus. D: 10% dextrose is a form of glucose and is not indicated in the treatment of diabetes insipidus.
Question 7 of 9
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Lymphangitis is an inflammation of lymphatic vessels. 2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection. 3. Nurse should notify the physician for further evaluation and treatment. 4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification. 5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification. 6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.
Question 8 of 9
A client with human immunodeficiency virus (HIV) undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:
Correct Answer: C
Rationale: The correct answer is C because a lack of response to intradermal anergy testing suggests an inability to mount a normal delayed-type hypersensitivity response, indicating immunodeficiency. This could be due to conditions such as HIV, which impairs cell-mediated immunity. Choice A is incorrect because absence of reaction does not necessarily indicate lack of previous exposure to antigens. Choice B is incorrect as the absence of response doesn't confirm the presence of antibodies. Choice D is incorrect because anergy testing is not used to assess allergy, but rather to evaluate cell-mediated immunity.
Question 9 of 9
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: The correct answer is D: Proper positioning. Proper positioning helps maintain joint alignment, prevents pressure ulcers, and reduces the risk of contractures by keeping the muscles in a neutral position. This is crucial in preventing complications associated with spasticity. A: Active exercise may exacerbate spasticity and lead to muscle fatigue, increasing the risk of contractures. B: Use of tilt board may not directly address the need for proper positioning to prevent contractures. C: Deep massage may provide temporary relief but does not address the underlying issue of maintaining proper positioning to prevent contractures.