ATI RN
Nursing Process Exam Questions Questions
Question 1 of 5
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
Correct Answer: B
Rationale: The correct answer is B: Take a deep breath as the nurse deflates the cuff. This is the correct choice because asking the client to take a deep breath while the cuff is deflated helps prevent aspiration of secretions into the lower airway. When the cuff is deflated, the tracheostomy tube provides a direct pathway for secretions to travel upwards, and taking a deep breath facilitates the movement of secretions out of the trachea. Choice A (Cough as the cuff is being deflated) is incorrect because coughing while the cuff is being deflated can increase the risk of aspiration as secretions may be forced into the lower airway. Choice C (Hold the breath as the cuff is being re-inflated) is incorrect as holding the breath while the cuff is being re-inflated can hinder the clearance of secretions from the trachea. Choice D (Exhale deeply as the nurse re-inflates the cuff) is incorrect
Question 2 of 5
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
Correct Answer: B
Rationale: The correct answer is B because the client remains radioactive for a period of time after the implant removal, typically around 10 days. During this time, the nurse should take precautions to limit exposure to radiation. Choice A is incorrect because bodily fluids are not highly radioactive, and proper disposal procedures should be followed. Choice C is incorrect as soiled linens should be handled appropriately to prevent contamination. Choice D is incorrect as bed rest may not be necessary, and mobility should be encouraged within safety guidelines.
Question 3 of 5
A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
Correct Answer: D
Rationale: The correct answer is D because a respiratory rate of 8 breaths/min indicates respiratory depression, a serious adverse effect of morphine. Morphine is a central nervous system depressant that can suppress the respiratory drive, leading to hypoventilation and potentially respiratory failure. This is a life-threatening complication that requires immediate intervention. A: Voiding of 350mL of concentrated urine is not typically associated with morphine use. B: An irregular heart rate of 82 beats/min is within a normal range and not a common adverse effect of morphine. C: Pupils constricted and equal is a common side effect of morphine due to its action on the central nervous system, not necessarily indicating an adverse effect.
Question 4 of 5
A client has malignant lymphoma. As part of her chemotherapy, the physician prescribes chlorambucil (Leukeran), 10mg by mouth daily. When caring for the client, the nurse teaches her about adverse reactions to chlorambucil, such as alopecia. How soon after the first administration of chorambucil might this reaction occur?
Correct Answer: B
Rationale: The correct answer is B: 2 to 3 weeks. Alopecia (hair loss) is a common adverse reaction of chlorambucil, typically occurring 2 to 3 weeks after the first administration. This is due to the drug's effect on rapidly dividing cells, including hair follicles. Immediate onset (Choice A) is unlikely as it takes time for the drug to affect hair growth. One week (Choice C) is too soon for alopecia to manifest. One month (Choice D) is too long as alopecia usually occurs earlier. Therefore, the correct window for alopecia onset after chlorambucil administration is 2 to 3 weeks.
Question 5 of 5
In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:
Correct Answer: C
Rationale: The correct answer is C: Uterine body. The rationale is that the most common site of cancer for females is uterine body, specifically endometrial cancer. This is due to the high prevalence of hormonal imbalances and estrogen exposure, which are risk factors for this type of cancer. The other choices, A: Uterine cervix, B: Vagina, and D: Fallopian tube, are less common sites of cancer in females compared to the uterine body. Understanding the prevalence and risk factors associated with each site of cancer is crucial for nurses to educate clients effectively.