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 client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
Correct Answer: A
Rationale: The correct answer is A: Decreased serum sodium level. In SIADH, there is an excessive release of ADH, causing water retention and dilution of sodium in the blood. This leads to hyponatremia. B: Increased blood urea nitrogen and C: Decreased serum creatinine level are not typically associated with SIADH. D: Increased hematocrit is not a typical finding in SIADH, as it is more related to dehydration. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level due to dilutional hyponatremia.
Question 3 of 9
An agitated, confused client arrives in the emergency department. The client’s history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
Correct Answer: C
Rationale: The correct answer is C: 10 to 15 g of a simple carbohydrate. This amount of carbohydrate is recommended for treating hypoglycemia in clients with diabetes to quickly raise blood glucose levels without causing hyperglycemia. Consuming too little carbohydrate may not effectively raise blood glucose levels, while consuming too much may lead to a rapid spike followed by a rebound hypoglycemia. Options A and B provide insufficient amounts of carbohydrate, while option D provides excessive carbohydrate, increasing the risk of hyperglycemia. Therefore, option C is the most appropriate choice for effectively treating hypoglycemia in this client.
Question 4 of 9
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
Correct Answer: C
Rationale: The correct answer is C. This statement warrants clarification as donating blood does not put individuals at risk of getting HIV. Blood donation involves a sterile process that ensures safety. Choice A is correct as using condoms can help prevent the transmission of HIV. Choice B is incorrect because modern blood screening techniques have greatly reduced the risk of HIV transmission through blood transfusions. Choice D is also correct as sharing needles is a high-risk behavior for HIV transmission. In summary, only choice C is incorrect as donating blood does not pose a risk of acquiring HIV.
Question 5 of 9
According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.
Question 6 of 9
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
Correct Answer: B
Rationale: The correct answer is B: "Keep the stoma dry." Keeping the stoma dry helps prevent infection and skin irritation. Moisture can lead to fungal growth and skin breakdown. Option A is incorrect because keeping the stoma uncovered can increase the risk of contamination and infection. Option C is incorrect as self-care promotes independence and allows the client to become familiar with the procedure. Option D is incorrect as moisture can lead to skin issues.
Question 7 of 9
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 their health care. By focusing on the patient's expectations, the nurse can establish a therapeutic relationship, provide patient-centered care, and tailor the care plan accordingly. A: Nurse's concerns - Incorrect. The nursing health history should prioritize the patient's perspective and needs over the nurse's concerns. C: Current treatment orders - Incorrect. While important, this component focuses on the medical treatment plan rather than the patient's expectations. D: Nurse's goals for the patient - Incorrect. The nurse should collaborate with the patient to set goals that align with the patient's needs and preferences, not impose their own goals.
Question 8 of 9
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
Correct Answer: B
Rationale: The correct answer is B because Toni's behavior of minimizing her visual problems, focusing on future goals, seeking information about job opportunities, and expressing desire for more children reflects coping mechanisms used to deal with the exacerbation of her illness. This behavior suggests that she is trying to maintain a sense of normalcy and control in the face of her health challenges. A: Inappropriate euphoria is excessive happiness or excitement, which is not evident in Toni's behavior. C: Remission phase typically involves a decrease in symptoms, which is not reflected in Toni's situation. D: Realistic for her current level of physical functioning does not explain her behavior as coping mechanisms.
Question 9 of 9
. A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client:
Correct Answer: B
Rationale: Rationale: 1. Oral antidiabetic agents target insulin resistance, common in type 2 diabetes. 2. Type 1 diabetes lacks insulin production, making oral agents ineffective. 3. Choice A is incorrect as insulin cannot be taken orally. 4. Choice C is incorrect as oral agents are not indicated for type 2 diabetes. 5. Choice D is incorrect as pregnancy does not affect the type of diabetes.